GW1-2021-04662_Well Construction - GW1_20210514

`; Print Form -
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,�
Nathan Seagle y�.� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
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4499-A Ultii
ft. ft.
NC Well Contractor Certification Number i ft{IGII,31% ' ����i0(1 15.OUTER CASING for malti�ased wells OR LINER if s !cable
Aqua Drill, Inc. ��� FROM TO DIAMETER THICKNESSI MATERIAL.
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Company Name 16.INNER CASING OR TUBING othermal closed-loop)--_
2.Well Construction Permit#: &)S t yl IF -O 11 Vial- 2021 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL In.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Er ical/Publicft. ft. in.
Geothermal(lieating/Cooling Supply) delpntial Water Supply(single) It. ft. in:
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
14
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licsble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach`additional sheets if necessary)
Geothermal (Heating/Cooling Return) r30ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfmck type,grain size,etc
.p D e. Ib rL
4.Date Well(s)Completed: ,S- 0-z/ Well ID# go
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5a.Well Location: ft. rr-1
a
Facility/Owner Name Facility ID#(if applicable) ft• It.
ft. ft.
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Physical Address,City,and Zip ft. ft.
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21.REMARKS
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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 , G/G/�Sf� S- %?- zI
6.Is(are)the well(s) rmanent or 137remporary Signatu Certifi r Date
By signing this form,I by certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ro 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 ofthis 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: 6 ar (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 4/0 (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: ld (in.) 24b.For Intection 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: 041 r ,n✓'/ /Z 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) r Method of test: C4'{i e- e hy)y, 24c.For Water Supply&Iniection Wells: In addition to sending the form to
G 2- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 76 completion of well construction t�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