GW1-2021-04307_Well Construction - GW1_20210430

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Nathan Seagle �. -w, 14.WATER ZONES i
g.,, .� i,l t", FROM 'I'O DESCRu rION
Well Contractor Name
4499-A `"'" :�
rj7,�g/ 202i ft. ft.
NC 1Vcll Contractor Certification Number 15.OUTER CASING for multi=cased trolls OR LINER ifa lieablc
Aqua Drill, Inc. �1vnt C3CriId�Lnel� FROM To DIAMETER THICKNESS MATERIAL
Company Name iiSv s:"t011 C7 17> 4 W a l�
16.INNER CASING OR TUBING geothermal closed-loop)
2.Well Construction Permit#: �� , FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Mutucipal/Public ft ft. in
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in;
IndustriaVCommercial Residential Water Supply(shared) 18—GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q
fL ft'
-
Monitoring DRecovery ft. ft.
injection Well: ft ft
_ Aquifer Recharge [3Groundw ater Rcmcdiation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery [3Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13subsidcnce Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOGI attach additional sheets if necessary
Geothermal eatin Coolin Return Other(explain under#21 Remarks FROM To DESCRIPTION(color,hardness sollhrock nano sirs eta
rt. ft.
4.Date Well(s)Completed: Well ID# s ft. 3 ft.
Sa.Well Location:
ft. ft.
ft. ft.
Facility/Owner Name Facility[D#(if applicable)
ft. ft.
ft. ft.Fi117iQ ��rL ft. ft.
Physical Address,City,and Zip
�-iy'k
21.REMARKS
pis
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
?�
6.Is(are)the well(s)OPrmanent or OTemporary Signature o ertified n r Date
Br signing this form.1 heii95v certLfi,that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: []Yes or to with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Tf thLv Lv a repair,Jill out known well construction irrlbrtnation and explain the nature oJ'fire copy ofthis record has been provided tolthe well mvrrer.
repair under#21 remarks section or on the back ol'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 ofwelis construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 62 Z C` (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJjerew(example-3L200'and 2@100) construction to the following:
10.Static water level below top of casing: AM: (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use`+" 1617 Mail Service Center,Raleigh,NC 276994617
Aare-
11.Borehole diameter: (in.) 24b.For Injection 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: i N P I j 1 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 Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) Method of test: 24c.For Water Suppiv&Injection Wells: In 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: �/�GZ' 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