GW1-2021-04239_Well Construction - GW1_20210419

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Nathan Seagle 14.WATER ZONES
Well Contractor Name FROM 'to- DESCRIPTION
4499-A 2a tr. 1"2 . ft.
ft. ft.
NC Wcll Contractor Certification Numbcr 15.OUTER CASING for multi cased wells OR LINER If a' licn6lc
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
O ft. .0 ft. 6 1 ' in. 5DX-2 L
Company Name
16.1NNER CASING OR TUBING geothermal closed-too
2.Well Construction Permit#:2^4� 1 C 1 "4C fO 7-T76 FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable+yell construction permits(i.e. UIC,County,State, Variance,etc.) ft. tt. in•
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN'FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
:)Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
I Ti ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: v ft. 20 [t. e
Monitoring EIRecovery ft. ft.
Injection Well: ft ft
_ Aquifer Recharge oGroundwatcr Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT h1ETHOD
Aquifer Test [3Stormwater Drainage tt. ft.
Experimental Technology 13 Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach addlll6oafsheets if necessa" '
Geothermal eatin Conlin Retum Other(explain under#21 Remazks FROM TO DESCRrPTION color,hardness soil/mck c rain size etc
D ft. f o ft.
4.Date Well(s)Completed: 3-/S^-Z Well ID# tt. 3c, R•
5a.Well Location: 30 ft' GS ft' K
Facility/Owner Name Facility ID#(if applicable)
-
I027- '915/CIS f,1c�.J Lr�,.t ►^'tr" a 9
Physical Address,City,wd Zip
/ti19btG1�e911 rn� LC� 21.REMARKS
County Parcel Identification No.(PIN) in
g
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r�
r.r-n,
(if well field,one fattlong is sufficient) 22.Certification
•
N W Joe
6.Is(are)the well(s)am or Temporary signature of C e C clot Date
By signing this form.1 erebv certif,that the r,ell(s)seas(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or 94 - with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
I(tlris is a repair,fill out known well construction in(orntation and explain the nature ofthe copy ofthis record has been provided to'the xell owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
A.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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also,lattach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3L200'and 2(a) construction to the following:
10.Static water level below top of casing: ZS (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,rise
/'+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: !o (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 well
12.Well construction method: xfl enel l construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ZO Method of test: 51 S k} 24c.For Water Supply&Infection Wells: fit addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: />�f�} Amount: �( 02 completion of well construction to 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