GW1-2021-04240_Well Construction - GW1_20210419

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nathan Seagle 14.wATER ZONES
Well Contractor Name FROM TO DFSCR1rr►ON
ft. ft.
4499-A °
ft. ft.
NC Wcll Contractor Certification Numbcr 15.OUTER CASING far inu" cased Ivells OR LINER ifu Iieable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
O 11. s•5 11. / 1/L( in. 5,iti 2 i U C_
Company Name 16.INNER CASING OR TUBING geothermal closed-lon.
2.Well Construction Permit#: 2a zp OUGO-JZ-L-r FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)
3.Well Use(check well use): ft. ft, in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Municipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) [I asi'dential Water Supply(single) fL ft. in
Industrial/Commercial Residential Water Supply(shared)
IR.GROUT
Geothermal
Irrigation FROM TO MATERIAL. EMPLACEMENT METROD&AMOUNT
Non-Water Supply Well: ft• zo ft.
Monitoring Recovery
Injection Well:
Aquifer Recharge [3Groundaatcr Remediation qg.SAND/GRAVEL PACK ILI applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attneh'additional`shects if necessary
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM I TO DFSCRTPT►ON color,hardness,sonhnek type,grain size etc
C rt. 1.5
%
4.Date Well(s)Completed: 3-/7--2 Well ID# it. Lin
tt.
5a.Well Location: R. tt. ^'
ft. It.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip ft. ft. a
�Klv1� „1 n 21.REMARKS
County Parcel ilti
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
�/yrs',P, 3-17- Z i
6.Is(are)the well(s)Mnrmanent or 13Temporary SSignature of Certified e 1 Con or Date
By signing this form.1 hereby certify that the wells)w•as(were)constructed in accordance
7.Is this a repair to an existing well: nYes or QNo with 1 SA NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and that a
If this&a repair;fill out known well cown•uc•tion information and explain the nature of the cagy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this jbrm.
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 1 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: I45- (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diJfoem(example-3@200'and 2@1001 construction to the following.
10.Static water level below top of casing: Z (ft.) Division of Water Resources,Information Processing Unit,
ifwvater 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 this form within 30 days of completion of well
12.Well construction method: 191 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 C i enter,Raleigh,NC 27699-1636
13a.Yield(gpm) ZG Method of test: 24c.For Water SuoDly&Injection Wells: h)addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.'Disinfection type: Amount: dZ 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 Rater Resources Revised 2-22-2016