GW1-2021-02258_Well Construction - GW1_20210514

Pont or
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Nathan Seagle = 14.WATER ZONES
Well Contractor Name FROM ft• "fO n DESCRIPTION
4499-A
p 1 �
NC Well Connector Certification Number n 15.OUTER CASING for multi cased''wells OR LINER it applicable)
Aqua Drill, Inc. sS1i��UVll� FROM TO DIADIETF.R THICKNESS MATERIAL
• r`"�V� ft. Yt. �114 in.
Company Name ,. 1,.3 a J•�t� t tf 2
I&INNER CASING OR TUBING:Wiftermal closed-loop)
2.Well Construction Permit#: FROM TO DiADfETER THICKNESS MATERIAL
List all applicable well construction permild-6.e.UIC,County,State, Vwiance,etc•.) tt. ft. tn•
3.Well Use(check well use): ft. ft. in.
17.SCREEN
[In
r Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
icultural ®Municipal/Public ft ft. in.
thermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft In..
ustrial/Commercial Residential Water Supply(shared) 18 GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Water Supply Well: n. n.
nitoring Recovery ft. ft.
tion Well:uifer Recharge ®GroundwatcrRemediation99.'SAND/CRAVELPACK'rfa licabtcuifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
uifer Test [3Stormwater Drainage ft. ft.
erimental Technology Subsidence Controlthermal(Closed Loop) Tracer 20:DRILLING LOG atiachadditional sheets if necessathermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM I TO DESCRrPTION color,hardness,sotltmic rain sire eta
ft. ft.
4.Date Well(s)Completed:��Zvi—Z` Well ID# 110 ft
• n•
5a.Well Location: 0 ft. I7-0 ft.
(:!4c 20
Facility/Owner• me Facility ID#(if applicable)
Ct. ft.
Fy ( TrGr I n ft. n.
Physical Address,City,and Zip
ft. ft.
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
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified well Date
By signing this form.1 hereby ce t that the uell(s)nos(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or [3No with 15A NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a
Ifthis&a repair,fill out known well consn uction information and explain the nature of the copy of this retord has been provided to the%ell owner.
repair tinder#21 remarks section or on the back afihis 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: ZGf (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths if different(example-3(at200'and 2@100') construction to the following: i
10.Static water level below top of casing: 3e3 (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 Injection 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: Inn t t} 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 276994636
13a.Yield(gpm) �� Method of test: s_ 1 24c.For Water Supply&Iniection,Wells: hi 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: 1� o Z completion of well construction toy 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