GW1-2021-04232_Well Construction - GW1_20210419

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: f
1.Well Contractor information:
Nathan Seagle .14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
&0 ft' 1 ft'
4499-A
NC Well Contractor Ccrtification Number 15.OUTER CASING for muhi-cased gvells OR LINER if a Iicablc
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft' 65- ft' AI.
in. 5P Z lJ C
16.INNER CASING OR TUBING geothermal closed-loop)
2.Well Construction Permit#: 3 Ll 5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Vm•ianee,etc.) ft. R. in.
3.Well Use(check well use): ft. [t. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.'I
Industrial/Commercial Residential Water Supply(shared) iR.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. Z6 ft.
Monitoring 13Recovery
injection Well:
Aquifer Recharge E)Groundwatcr Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stotmwater Drainage
Experimental Technology 13 Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional shee►s'if necessa`
Geothermal eatin Cooling Return Other(explain under#21 Remarks FROM To DESCRIPTION color,hardness sontrock min slzc etc
O ft. (C, ft.
G
4.Date Well(s)Completed: 3-��-Z) Well ID# O ft. 40 ft. S 'Rock
5a.Well Location: Wei
ft. 60 ft. o
ck
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip ft. ft. tl',i �9 "' •v
SAa K'-C 21,REMARKS
County Parcel Identification No.(PIN)
"l'';,::il ^.rDSiIIE�Unit
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r-•� �� L,^^_
(ifwell field,one tat/long is sufficient) 22.Certification' DIVIV r.�SCC.OP
N W
3-]l' z
6.Is(are)the well(s)MP.et'1Hanent or Temporary Signature ofCertWf&'7;$PP1Vmctor Date
Al,signing dtis form.I hereby certifi that the well)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or _ with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
!(this is a repair,Jill nut known well cnnsn•uction infbnmation and caplain the nature oJ'tire copy of this record has been provided to the well oiwter.
repair tinder#21 remarks section or on the back of this Jbrm.
23.Site diagram or additional well details:
A.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: S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJjerent(example-3L200'and 2@100') construction to the following:
10.Static water level below top of casing: S (ft.) Division of Water Resources,Information Processing Unit,
If,vater level is above casing,use + 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter: (in.) 24b.For Infection 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'//'t'Ja-/.// 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) ZS Method of test: st sl.) 24c.For Water Suppiv&Infection 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: �G completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016