GW1-2021-04635_Well Construction - GW1_20210514

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nathan Seagle s 14.WATER ZONES
It1P
Well Contractor Name FROM TO DESC VON
1.
4499-A 4 2021
ft ft
NC\Vd Pv4AY 1l Contractor Certification Number �q a 15.OUTER CASING for;mulli-Ased wells OR LINER ifa °licable
Aqua Drill, Inc. '%-G1113i'Ivi1 P,0r ees!10 Unit FROM TO DIAMETER THICKNESS MATERIAL
Company Name
16.INNER CASING OR TUBING eo ermahclosed-loo
2.Well Construction Permit#: �O�I O O/J?� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consbuction permits(i.e.U1C,County.State, Variance,etc.) ft. ft. In,
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. ft.
v
Monitoring Recovery ft. ft.
injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Rcmcdiation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additioiYal sheets if necessar
Geothermal eatin ooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,sollftek type,grain size eta
ft. [t.
4.Date Well(s)Completed: L/-Z 7-Z L Well ID# 00 ft. tle) ft.
ft.
Sa.Well Location: L tJ ft.
ft. ft.
Facility/Owner Name Facility lDff(ifapplicable) ft. ft.
"/S" �,hnrsl���& ft. rt.
Physical Address,City,and Zip
ft. ft.
( nt �L( 4 21.REMARKS
CCountyP 0�4. Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tattlong is sufficient) 22.Certification:
N w L/-7-7-Z/
6.Is(are)the well(s)OW—anent or Temporary Signature o rtified we Date
/ By signing this form,1 hereby�ZCV
e uell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or �AtG with I5A NCAC 02C.0100 o} C.0100 Well Construction Standards and that a
Ifthiv 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 ovvier.
repair tinder#11 remarks section or on the back ofihisform.
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 ifnecessary.
drilled: p SUBMITTAL,INSTRUCTIONS
9.Total well depth below land surface: 7- D (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For niuhiple welly list all depths ifdi(jerent(example-3L200'and 2(a3100') construction to the following:
10.Static water level below top of casing: 2 S'r (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: // in.
lrl�(in.) 246.For Iniection Wells: In addition to sending the form to the address in 24a
f� j/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) Method of test:, .e^ y� 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: OZ 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