GW1-2021-01408_Well Construction - GW1_20210322

Print FtNm
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Nathan Seagle I4.W'ATER ZONES
CunUactor Nam< INOM 10 DF5('R1rl]ON
ft.
4499-A ,r fl.
n. n.
K('wd ('mmacnn('eniiioauon Number 15.OUTER CASING far muBFeased week OR LINER(ifie Reaiat
Aqua Drill, Inc. FR11fi DIAMETER I 1'IIICKNfm MdTFR1U.
/ in. ls"DR-7_1
/ '
('umpany Name
q 16.INNER CASING OR TUBING eothermd cloxd-1
2.Well Construction Permit#:�ILkr� ZL./ZL�CJ 3�1/�(1 FROM 1'0 DIAMETER THICKNEcS I MATERLAI.
LIs,ell eppGrnh7r lved/am�hva rwrz pravni(s G.e b/C.Cuvwl Star,. rw donee.eh.) f1. fl. in.
3.Well Use(check well use): n. ❑. is.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT`47k 71111KNES4 M,AIFRUI.
:\gricultual Municipal Public ft. ft. is.
Geothemlal(Heatime Cooling Supply) E]{Cesidential Water Supply(single) n ft in.
Indusnal,Conunercial Residential Water Supplp(shared) I&GROUT
Irn'anon FROM TO MATERIAL EMPLACEMENT METHOD&A,MOL NT
il
Non-Water Supply Well A. Ift
_Monitoring Recovery ft.jection Well: ft.
Aquifer Recharge E3Gmundw ater Rcmcdiation 19.SAND/GRAVEL PACK f kabk
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stomosater Drainage ft. ft.
Fsperimental Technology Subsidence Control ft. ft.
Cicothelmal(Closed Loop) 13TmLer 20.DRILLING LOG(attack additional slaves if
(Geothermal(Heating(ooling Return) rJOther(explain under A21 Remarks) 1
FROM TO DESCRIPTION mlo..h.W..% imil.rue cm.l
4.Dave Well(s)Completed: 3- LI Well IDee ft. !CV)
ft. L .
Sa.Well Location: D.
C- ft. r fl.
i
I acdio 0wewi Sans Facili, lD'I il'appl,c7N ft. A.
/G/�/ /s' ft.
Ph..irul Add.....City.and zip fl. It
21.REMARKS
S��rn.t ,
County Parcel IdenutwaGon No.(PIN)
5b.Ladmde and longitude in degrms/minutes/seconds or decimal degrees:
(dwell Geld one lalllany l sulTidenl) 22.Certification:
N W - G 3- 5
6.[slave)the weli(s)OPermareent or 01remporaq' Signature of('enifig�y cror Dale
^'�� B,starnA Ili (ono l� rein enfii Itle ell/1 ' (were;corm rd ccodanar
7 Is this a repair to an existing well Yes or l.l� .vn 114 AC4(() 6.man /rA x fC 0 C 0 00;Fell( r-Trial e, d ja ale,hm a
Ilrh'.-i Bair,pl[ourbunco url/-n-vve,i,n mfi f nand erplain,he nawrra/the '/^- rr/i. n,r nl Au hen per ,drdn ,h,.ellonler
calorie gorier#21 remarks Saban or on the bark of this loan.
- 23.Site diagram or additional well details:
R.For Geoprobe/DFT or Closed-Loop Geothermal W ells has ing the same You may use the back of this page to provide additional well site details or well
consmction.onl) I GW-I is needed. Indicate TOTAL.NUMBFR ofcvelis constmclion details. You may also mach additional pages i(necessary.
drilled: 7 SUBMITTAL,INSTRUCTIONS
9."total well depth below land surface: 3 O r Ift.) 24a• For All Wells: Submit this morn within 30 days of completion of well
F..nmlriple welly li.rr nil drprhe J Jplrrrnr luran0dv-3(,200" e,u/t'a Hyf) construction to the following:
10.Static water level below top of casing: zs (ft.) Division of Water Resources,Information Processing Unit,
//nnrrr/reel Lr above rnvmy.use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Induction Wells: In addition to sending the foml to the address in 24a
_ above, also submit one cop}of this forth within 30 daps of completion of well
12.Well construction method: A It'IZ�� construction to the following:
I i.e.auger.rotary,cable,direct push em.1
Division of W ater Resources,Underground Injection Control Program,
FOR W ATER SUPPLY W ELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 636
13a.1field(gpm) Method of test: 24c. For Water Sma ly & Injection Wells: In addition to sa)ding the form to
the address(es) above, also Submit one cop)' of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Furor G W-1 North('amlina Department of Environmental Quality-Divi�mn of\Aster Reauurces Reciscd 2-22-2016