GW1-2021-04346_Well Construction - GW1_20210408

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Nathan Seagle �..,., '; 14.WATER ZONES
Well Contractor Name ' ),�, l� FROM TO DESCRIPTION
4499-A d ft-
NC
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NC Weil Contractor Certification Number r1
nrfa°,�Sr ,V)g}j{ 15.OUTER CASING for multi-cased yells ORLINER ifa licable
Aqua Drill, Inc. )It�.iT11,i�IC11 Y:""' FROM TO DIAMETER THICKNESS MATERIAL
Company Name
16.INNER CASING OR TUBING eothermat closed-loop)
2.Well Construction Permit#: r✓,/�1/�-t7 /��/ 8 i FROM TO DIAMETER THICKNESS RI MATEAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc•.) tt. fr. In.
3.Well Use(check well use): tt. fr. in.
17.SCREEN
Water Supply Well: FROM TO DIAIUETER SLOT SIZE TRICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) sRential Water Supply(single) ft. ft in.
Industrial/Commercial 13Residential Water Supply(shared) I&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fr.
Monitoring Recovery ft. ft.
Injection Well: 0. ft.
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal (Heating/Coolie Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soft/inek type,grain slue etc
O ft. ft.
4.Date Well(s)Completed: LI�Z i Well ID# ft• 410 ft. o _ s
5a.Well Location: ft. .52 ft.
ft. fr.
Facility/Owner Name Facility ID#(ifapplicable) ft. fr.
J ;!Sf2,
Physical Address,City,and Zip
ft. fr.
21 REMARKS
\Id4 L2 1
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
3 -�1�21
6.Is(are)the wells) Permanent or Temporary Sigoati e o CertT5W1et C "`or
Date
By signing this form.j4rerety cerlifv that the well(s)wus(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or o with 15A NCAC 02 .0100 or i5A NCAC 02C.0100 Well Construction Standards and that a
!f tliis 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 of this form.
23.Site diagram or additional well details:
R.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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V12s (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all deptlis ifili ferent(example-3(ig200'and 1(a3100') construction to the following:
10.Static water level below top of casing: 3 U (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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 ttiis form within 30 days of completion of well
12.Well construction method: �J�l_I I construction to the following:
(i.e.auger,rotary,cable,direct push did.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test:Z+ 24c.For Water Supply&Iniectlion Wells: In addition to sending the form to
the address(es) above, also subtriit'one copy of this form within 30 days of
13b.Disinfection type:_4 z Amount: /w a2 completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource i s Revised 2-22-2016