GW1-2021-04259_Well Construction - GW1_20210419

i
Print Form
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Nathan Seagle 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
4499-A
rt. ft.
NC Wcil Contractor Certification Number 15.OUTER CASING for multi-cased wells RLINER(Ifap Ilcable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
O ft. ft. / r 5 (JC
Company Name L�
_ ['' 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: L..957mi 1— o i O T5- za-L l FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Vit lance.etc.) ft. fr. In.
3.Well Use(check well use): ft' ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft is
Industrial/Commercial Residential Water Supply(shared) JR:GROUT'
Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. ft.
Monitoring E3Reco,,ery ft. ft.
injection Well:
Aquifer Recharge []Groundwater Rcmcdiation 19;SAND/GRAVEL PACK(Ira licablc
Aquifer Storage and Recovery [3Salinity Banter FROM TO MATERIAL EMPLACEMENT NIETHOD
Aquifer Test 13Stomiwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach edditionalisheetsif neeesis"
Geothermal eatin Coolin Retum Other(explain tinder#21 Remarks) FROM To DESCRIPTION rotor,hardness soNrock rain slim e[c
b rt. ft.
4.Date Well(s)Completed: 3—3—21 Well ID# ft. o ft. 1
ft. ft.
Ste.Well Location:
I
go <zA4rJ :RCA
ft. 2.2-. ft-
Facility/Owner Name L Facility ID#(if applicable)
!re.!;7l/y)G 14� ft. fL oa3
Physical Address,City,and Zi ft. ft. 1 'v
Ys ty, p
a
21.REMARKS
ILI
Co my G Parcel Identification No.(PIN)
Uillt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r �rrci7) 7
(if well field one lat/long is sufficient) 22.Certification
N W
6.Is(are)the well(s) Finanent or OTemporary Signature of Certifie&17ell C ctor Date
By signing this form.1 hereby cerafv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
#this is it repair,fill out known well comtruction inlorination and en7dain the nature of the copy of this record has been provided to the yell owner.
repair under#11 remarks section or an the back of this form.
23.Site diagram or additional well details:
8.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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also,attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 ZS (fl-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerea(example-23L200'and 2Lin l00') construction to the following:
10.Static water level below top of casing: b (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Syr / / above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:�l r�^/ � 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) 5 Method of test: 'JI^G 24c.For Water Suoahv&Injection Wells: hi addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount: �- 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