GW1-2021-01068_Well Construction - GW1_20210322

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nathan Seagle 14.WATER ZONES
FROM '10 11"CRIY'110R
Well Contractor Name n. .r n.
4499-A LfL
n. n.
NC\C ell Contractor Ccnitication\umber 15,OUTER CASING for multbeased wells OR LINER(if so litable
Aqua Drill, Inc. FROM ft. 1'0 ft. DIAM81'I:R THICKNUSS MATERIAL
Cmnpnny Name
FROM
INNER CASING OR TIIBDIG tolhermal clERKNtoo
2.Well Construction Permit S: N(1" 0�'`Q �� 3��� FROM TO DIMIETER TIIICKNFSS MATERIAL
Lisrell upp6rahlr turd!oonvvumm�pnmirs ri.e. LIC.C'ounp.Shire. E'urimar.rrrl ft. D, in.
3.Well Use(check well use): ❑. n. is
17.SCREEN
Water Supply lYdl: FROM TO DIAMETER SLOTFIZE 1'mCKNM1 MATERIAL
Agricuhurel Municipal Public II, fE In
Geothermal(Heating('oohng Supply) �esidenlial Water Supply(singlet
IndustriaUConunercial Residential Water Supply(shared) ULGROUT
Irrigation FROM 10 NIATERLU, EMPLACEMENT METH OD&AMOUNT
N'on-Water Supply Well: C) " Zt, rt.
Monitoring Recovery ft. D.
Injection Well:
ft. R.
Aquifer Recharge QGrounde'ater Remedialiun
19.SAND/GRAVEL PACK(ifankahl0
Aquifer Storage and R2co\'cry E3Salinll3 Barrier FROM I To MATERIAL EMPLACEMENT METHOD
Aquifer Test aStornvater Drainage ft. ft.
Experimental'Technology Subsidence Control
Geothermal(Closed Lrxip) ®Tracer 20.DRILLING LOG aR¢h additional sheets if necessary)
Geothermal Ilealin Cooling Return) nOther(explain under ft2l Remakes) FROM To IDTsemIflON cobr,bardmx.,rolur«st nmslxe,ac.
o H. n' C/
4.Dale Well(s)Completed: Well IDq ft. Hp ft.
ft. It.
5a.Well Location: C.
1� �.��-1 11 rL 125, n. - el
I a,,lit,(Inner m Nae I'acilav lD=oI applicable) ft. R.
ft. n.
2tzo c r t n C tit la D.
Pbysical Address,City,and Zip
'� LI I 2LREh1ARKS
Country Parcel Identiit.niun No (PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(Twell Held one[.I I.u,Is sudieienO 22.Certification:
N W �� ,
6.1s(are)the well(s)OPPrmanent or ❑Temporary Signature o Ccrt�ifii t�r}It n'ir-a �f( ^T Date
0
I--I�— B'sigldrg rids loon. 7/rer v renh'dmr the ncrll(o nos pvere/'meow"M m vaordmae
7.Is this a repair to an existing well: Yes or Earn wah I5d NCAC 02C'.0100 or/5A NCAC 02C 0200 Well Constoi,ucn Standards and that u
It th"k u repair,fill our A ur//rnuvnv,mot Inlr.....i...and ecp)aia the nuru t,of rhr rn/n• if IN,rerard h.heea provided to the null mwrar.
repair under 421 remurke sr.5loo ur at the bacA qj this Jonn.
23.Site diagram or additional well details:
8.For Geoprobe/DFT 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: SUBMITTAL LNSTRUCTIONS
9.Total weil depth below land surface: I ZS eft•) 24a, For All Wells: Submit this form within 30 days of completion of well
R.r construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lltmrrr level is above rnring.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 this form within 30 days of completion of"ell
12.Well construction method: I v- I)n I-t construction to the following:
It v auger,rotury,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 636
13a.Yield(gpm) 3C Method of lest: `J t 5 Lr t 24c. For Water Suuuly& Infection Wells: In addition to sending the form to
the addTCSS(eS) above, also submit one copy of this form within 30 days of
13b.Disinfection type:&4 4j AmounC I C C 1 completion of well construction to the county health department of the county
where constructed.
Fomm G W-I North Carolina Deportment of Environmental Quality-Division of!Pater Resources Re,feed 2-22-2010