GW1-2021-04663_Well Construction - GW1_20210514

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: a 9 3
Nathan Seagle 14.WATER ZONES
�- FROMITO DESCRIPTION
Well Contractor Name q+ tDa 4499-A tyil�Y 1 NC Well Contractor Certification Numberft
� �,bi1 u t 45.OUTER,CASING formolhtasedwells OR LINER Ifa licable
Aqua Drill, Inc. 1 0m' nyhUR v�',C'1'0� FROM TO DIA11tETER THICKNESS MATERIAL
Company Name 1 6 ft. a R. ley
in. 2 -D U�,
16.INNER CASING OR TUBING `othermal closed-loo f
2.Well Construction Permit#: G,15 M 67 1 Z 0 'j FROM TO DIAMETER THICKNESS MATERUL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) % ft in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in..
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft ft In
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
IITI ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 70 ft.
Monitoring DRecovery ft. ft.
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
19 SAND/GRAYEL:PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Hearin Coolie Return) Other lain under#21 Remarks) FROM To DESCRIPTION color,hardness,eoillrock a rain a eta
c7 ft. I O ft
4.Date Well(s)Completed:,5 - 1 D 7-1 Well ID# 14
ft. ?O ft' G�•}
5a.Well Location: ft. n - ft f(
r C ft ft
Facility/Owner Name ✓ //Facility ID#(if applic t
-/ able) ft. f
to r 1�1Q YL erCJ—��iCl(� J) ft. ft
Physical Address,City,and Zip t ft. tt.
2L 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 tr 16 --Li
6.Is(are)the well(s) ermanent or 13Temporary SignatureWfCertifilopo� .ctor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or 'No- with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 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 1 GW-I 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-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: V- 0 (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 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: Ato o'-I&/ 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 27699-1636
13a.Yield(gpm) Method of test:e-'aAdi 24c.For Water Supply&Injection 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 type: Amount: 740 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016