HomeMy WebLinkAboutGW1-2021-04696_Well Construction - GW1_20210521 '�P,r:in fForm
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nathan Seagle °.'t 14.WATER ZONES
N,,y` '� m+� FROM TO DESCRIPTION
Well Contractor Name t �1 !s+ ft,
t ft.
4499-A t v
t
c��AY 21 2�21 ft. f
NC Well Contractor Certification Number ry `35.OUTER CASING for multi-cased wells OR LINER da licable
Aqua Drill, Inc. 7 r.0 s5113 UtllZ FROM TO DIAMETER TLIICIQVESS MATERIAL
G "3'k?�11 t r ft. ft. j� in. s
Company Name T `` O
`16.INNER CASING OR TUBING(geothermal dosed400
2.Well Construction Permit FROM To DIAMETER THICKNESS MATERIAL
h ft
List all applicable well construction permits(i.e.Ul�nty,n , ate,Variance,etc.) 1n.
3.Well Use(check well use): ft' ft in.
Water Supply Well: 11SCREEN
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL.
Agricultural [3Municipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) �Rsidential Water Supply(single) ft ft.
Industrial/Commercial 13Residential Water Supply(shared)
18.GROUT
Itri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. 20 ft
Monitoring 13Recovery ft. ft
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,bartiness,soilirock type,gmin size,eto
ft ft
4.Date Well(s)Completed: N-21-7 L Well ID# ft. ft.
Sa.Well Location: ft. 76 ft
w gaT-ft
Facility/Owner Name Facility lD#(if applicable) ft. ft'
` ft ft
�fit'`�TC�� is G' ' ft. ft
Physical Address,City,and Zip
/4dlG sit 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification:
6.Is(are)the well(s) P manent or 13Temporary Signature ofCertified)yr ontra Date
By signing this form,I hereb certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or &Pu- with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature ofthe copy of this 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:
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: 56 f (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 r@200'and 2@100D construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (2 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of tliis form within 30 days of completion of well
12.Well construction method: A I v- t7 n t 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
•-7 j' r
13a.Yield(gpm) 1 Method of test:C: �Y 1 v►,c 24c.For Water Suoaly&Iniection 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: 4' Amount: �fi Z completion of well construction to the county health department of the county
where constructed. 4
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016