GW1-2021-04661_Well Construction - GW1_20210514

tint form
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Nathan Seagle Ii 14.14O M TO DEscR WATER ZONES
Well Contractor Name IPTION
Ybo I rt.
4499-A AY 14 2021
ft, ft.
NC Well Contractor Certification Number
inS���i3�K;11'ryC^f�^Slri�lj7ilt ,-15:OUTERCASING formolti-casedwelis OR LINER ifa licable
Aqua Drill, Inc. FROM TO DLC14ETER TffiCKNESS MATERIAL
q [lvyn' sredon [t. in.
Company Name
16.INNER CASING OR TUBING 'othermal;closed-loa
2.Well Construction Permit#: CV15 h r O))"102 FROM TO DIAMETER THICKNESS MATFRrAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. is
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
r�llrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: r7 fL "'
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND1GRAVEL PACK if:a licitble
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology ®ISubsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG`attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM TO DESCRIPTKON rnlor,haraa sell/rocktype,gram size,eta
f L 2 ft
4.Date Well(s)Completed: Z--24 Well ID# iLze2tt.
5a.Well Location: tt. 3 S ft aAaZ
`
1 -vr' rn,1\ec w� ft. ,0 ft .
Facility/Owner Name Facility ID#(if applicable) ft' ft.
t1 Z,J 7 1 /G,//, �// ft. ft.
Physical Address,City,and Zip ft' ft
I`��LC7� i 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W �y �. ) 2
6.Is(are)the well(s) e-rmanent or Temporary Signature o Certified ctor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or BNo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on 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 I 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: (ft-) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example--r�33@200'and 2@100) construction to the following:
10.Static water level below top of casing:_,7V (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:�_ (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
II above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: T_ r l f r construction to the following:
(Le.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 276994636
13a.Yield(gpm) L/0 Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
G the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: )/ ld Amount: completion of well construction to ithe 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