GW1-2021-05441_Well Construction - GW1_20210503

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nathan Seagle 14.WATER ZONES
FROM TO DESCRUPTION
Well Contractor Name
4499-A
rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulli-cased wells OR LINER ira licabte
Aqua Drill, Inc. FROM TO DIAIIIETER THICKNESS MATERIAL
in.
Company Name
16.INNER CASING OR TUBING eothermatclosed400
2.Well Construction Permit 4: F&jLZI 9,03D2e- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc.) rt. R. in.
3.Well Use(check well use): it. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft. ft. in.'
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 7-0 ft. Mae .-Z
Monitoring Recovery ft. ft.
injection Well:
lGeothermal
Aquifer Recharge []GroundwatcrRemediation19.SAN0/CRAVELPACK ifa licabteAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test OStormwater Drainage ft. ft.Experimental Technology Subsidence Control ft. ft.Geothermal(Closed Loop) Tracer 20:DRILLING LOG attachadditionaliihectsifnecessarJ eatin C oling Return) Other(explain under#21 RcmarkL)j
FROM TO DESCRIPTION color,hardness,softtmck type,gnin size eta
Xe
O rt. lD ft.
4.Date Well(s)Completed: s;/_)S—ZI Well ID# 0 tt. ft• c
5a.Well Location: 50 tt. ft. 4
Facility/Owner Name Facility ID#(if applicable) rt. ft.
Z�� Sf 12tt2e-4 S� °r-
Physical Address,City,and Zip ft. ft.
21.REMARKS
S`"e-,Q,4 021
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 'Tag
t
(ifwell field,one tat/long is sufficient) 22.Certification: �j t§fit 3�E cE 0IL
6.Is(are)the wells) ermanent orITemporary Signorine of Certified e n r Date Z 1
By signing this form.I het certify at the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or o with 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
ft this is a repair,fill out known well construction information and explain the nature ofthe ceipy ofthis record has been provided to the well owner.
repair under#11 remarks section or on the back of this form.
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 I GW-I is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled:
I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �d.51— (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 2L700') construction to the following:
10.Static water level below top of casing: L/O (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use^+f' 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter: h (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 6`t i p '1): A 41 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, 7699-1636
i
13a.Yield(gpm) Method of test: k-/, Z' Tsss� 24c.For Water SuDDIv&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection t Amount: 30�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
I