GW1-2021-04690_Well Construction - GW1_20210521

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: l
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1.Well Contractor Information: �"`�'
Nathan Seagle �-- 14.WATER ZONES i I
Well Contractor Name 9 r �Orl FROM ft• TO ft• DESCRIPTION
4499-A
ro J�i1,Y� ft. ft.
NC Well Contractor Certification Number
is.OUTER CASING for mulli-cb'sed wells OR LINER ifa licable
Aqua Drill, Inc. 1"i+fit ��y j;� FROM TO DIADIETER THICKNESS MATERIAL
1J ft. ft. in.
Company Name
16.INNER1 CASING OR TUAING(geothermal closed-loo
2.Well Construction Permit#: 1 AwL ?o Zoo G 3 W FROM TO DIADIETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) tt. ft. in.
3.Well Use(check well use): tt. n. in.
Water Supply Well: 17.SCREEN
FROM TO DIADIETER SLOT SIZE THICKNESS I MATERIAL
Agricultural [3Municipal/Public % ft in.
Geothermal(Heating/Cooling Supply) EgRe5idential Water Supply(single) fL ft in.
Industrial/Commercial Residential Water Supply(shared)
lA.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery ft. ft.
injection Well:
!-)Aquifer Recharge []Groundviater Remediation ft ft
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidencc Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal eatin Coolin Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardnes soWmck type,grain size etc
4.Date Well(s)Completed: S—Gl Well ID# ft. ft.
5a.Well Location: �]ev�
Facility/OSWwnyee,Name Facility ID#(if applicable) ft. ft.
/4'mu Sr7".r"S 'RD ft. ft.
Physical AJ ess,City,and Zif ft. ft.
�. 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one Iatllong is sufficient) 22.Certification:
N W144,'<;�' -3 9- Z
6.Is(are)the well(s) Permanent or OTemporary Signature of CEIell tractor Date
By signing this form.I terebv cerfifi+that the well(s)ims(were)constructed in accordance
7.Is this a repair to an existing well: OYes or 0*a with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If Nnis Ls a repair,Jill out known well cnwir uction information and explain the nature aJ'the copy of this record has been provided to the well owner.
repair under#2i remarks section or on the back of this Jorm.
23.Site diagram or additional well details:
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may alsoattach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: 2•�'S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For-multiple wells list all depths if different(example-3L200'and 2ca))100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: to (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 191 r 10'1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l® Method of test: C�0,r6C fim e 24c.For Water Supply&Iniectilon Wells: In.addition to sending the form to
O the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:.- '-/1l Amount: Z Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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