GW1-2021-04633_Well Construction - GW1_20210514

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information: 7
e�4q
Nathan Seagle C � 1 14.lyATERZONES,
Well Contractor Name P�1AY 1 4 2021 FROM� fL TO ft. DESCRIPTION
4499-A
rsFS!!"i�Uszi1 ft. ft.
NC Wc1I Contractor Certification Number fi t1^vI1�•3eYi?nr'li t7�p`3C 15.OUTER CASING far multi-cased bells OR LINER if o licable
Aqua Drill, Inc. i�MYi'� 4 C.CI1 FROM TO DiM1ETER THICKNESS MATERIAL
ft. ft. t in.
Company Name
n-} ,.y 16.INNER CASING OR TUBING �eotherma[closed-loo
�`2.Well Construction Permit#: Vey oz. -' / FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. D, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Mtnticipal/Pablic ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fG ft. ta.
Industrial/Commercial Residential Water Supply(shared) 1R:GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: t�
Monitoring DRecovery ft. ft.
injection Well:
_.Aquifer Recharge [3GroundwatcrRemcdiation , i9..SAND/GRAVEL PACK ifn litatbie
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Coolin Return Other(explain under#21 Remarks FROM To DESCRIPTION color,hardness sotUrock rein sbs etc
ft. ft.
G
4.Date Well(s)Completed: LR-i 3'Z� Well ID# ft. ft.
5a.Well Location: ( ft. 5 ft.
�
d .
ft. L7 1r ft.
Facility/Owuer Name Facility ID#(if applicable)
Ll
Physical Address,City,and Zip ft. ft.
�1344 S ZS 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) ermanent or [ITemporary 'SiiggnaturFof Certified well Co ctor Date
By signing this form.1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3 Yes or Po with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
f tlfis Lv a repair,fill out known well construction infbrmation and explain the nature of the coin of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this Jorm.
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: S 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJjereni(example-3L200'and 2L1(10') construction to the following:
10.Static water level below top of casing: Z (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+^ 1617 Mail Service Center,Raleigh,NC 276994617
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 thiis form within 30 days of completion of well
12.Well construction method: 9 1✓'Dr t j 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
i
13a.Yield(gpm) Method of test:_4 4trr t X' 1:1 ft-e 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: Amount: 20 Z completion of well construction to 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