GW1-2021-00837_Well Construction - GW1_20210402

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- P.rint Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Nathan Seagle 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTTON
4499-A
e. tL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER TCKNESS MATERIAL
Q ft ft / //L in. 5 Z i1
Company Name t<' 1�
16.INNER CASING OR TUBING'(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
711 Agricultural 13Municipal/Public ft. ft. iN
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared)
]S.GROUT
hri atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. w ft.
Monitoring DRecovery ft. ft.
Injection Well: ft. fL
_Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
J Geothermal(Closed Loop) ®]Tracer 20.DRILLING LOG attach additional sheets ifnecessa
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrmk a rain 9 etc.
ft. ft
es
4.Date Well(s)Completed: `30 - Well ID#
ft. ft.
5a.Well Location: \ ft. ft 4
Facility/Owner Name Facility ID#(if applicable) ft. ft
ft. ft. f"
Physical Address,City,and Zip ft. ft
21.REMARKS
�
County_ Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
3t'100 Prof,-es
(if well field,one lat/long is sufficient) 22.Certification: D
N W �' `Q 3-30-zl
6.Is(are)the well(s),__: ermanent or Temporary Signature of Certified cur Dace
�,,/ 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: E)Yes or Epp with 15A NCAC 02C.0100 or 15A NCAC 02C.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 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� (it-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 1@I00) construction to the following:
10.Static water level below top of casing: 4M (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A r V e r l/ 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) 1.Z Method of test:cdtL_A Jr T.~_ 24c.For Water Supply&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: r Amount: -;!.6 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