GW1-2021-04343_Well Construction - GW1_20210408

PrntyForrn
WELL CONSTRUCTION RECORD WW-1) For Internal Use Only:
1.Well Contractor Information:
Nathan Seagle 14.wATERZONES 1 _
Well Contractor Name ,?, 1' FROM TO DESCRUMON
4499-A r ft. r
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for.muld-casedwella OR LINER rfa usable =
r`t. �.r'r�:l r:f Ldi el
Aqua Drill, Inc. �,;,,�,; _�, FROM To DWKEIER MATERIAL
Company Name ;u 7 IA. 6 ft. ✓o fR ! r is 5
16.INNER CASING.OR-TU IIN thermal dostddoo
2.Well Construction Permit#: �vl ✓7t7eiL-� 7 ►'T FROM TO DUNKIER THICIQVF.SS MATFRML
List all applicable i ell construction permits(i.e.UIC.County,State.Variance.etc) ft. 1°
3.Well Use(check well use): & & in.
Water Supply Well: 17.SCREEN -
FROM TO DLUMTER I SLOT SIZE I TMCKNM I MATERIAL
Agricultural C3Municipal/Public O ft ft. is
Geothermal(Heating/Cooling Supply) Ea sidential Water Supply(single) -ft. fL in
industrial/Commercial Residential Water Supply(shared) I&GROUT
'11irrigation FROM TO MATERIAL E"I ACEMEN[METHOD&AMOUNr
on-Water Supply Well:N 7G7
Monitoring Recovery fL fL
Injection Well:
fL ft, a _�
Aquifer Recharge [3Groundwater Remediation
19.'SANDIGRAVELPACK if a livable_
Aquifer Storage and Recovery OSalinity Barrier FROAT TO I MATERIAL EMPLACEMENT MMOD
Aquifer Test oStomiwater Drainage & ft .
Experimental Technology OSubsidence Control fL ft.
Geothermal(Closed Loop) E3TMM 20.DRILLING LOG attach additiondlsheets{f n
Geothermal(Heating/Cooling Return) rjOther(explain under#21 Remarks) FRoM TO DESCRDY14oN color, soil/rock siw-etc.)
IL
fL
4.Date Well(s)Completed: 3- 2--Z 1 Well ID# -y th - ft.
5a.Well Location: ft' ft
Cis® J FW�S ft ft04
FacDrty Owner Name Facility 1139(ifapplicable) ft ft
LIP
ft. %
Physical Address.City,and Zip & ft
21.REMARKS
County T Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
N W
6.Is(are)the wefl(s)g3ffmanent or OTemporary Signature ofCertifi, or Date
By signing this form,I h6by cereify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or [)No with 1SA NCAC 02C.0100 or i5A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out lurown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under R21 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 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: .� (ft) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 00'and 2@100) construction to the following:
10.Static water lave{below bop of casing: .0 (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,rise"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 24b.For Infection Wells: In addition to sending the fort to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:;Tt 4 2.t`I�� construction to the following:
(Le.auger.rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13%Yield(gpm) '34 Method of test: �5 24c.For Water Suooly&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:l/..CyZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofFinvironmental Quality-Division of Water Resources Revised 2-22-2016
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