GW1-2021-04344_Well Construction - GW1_20210408

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
Nathan Seagle 14.WATERZONES' k.
Well Contractor Name ^� it , FROM TO DESCRll r1ON
4499-A e' '
NC Well Contractor Certification Number 15.OUTER CASING'for mold cd'sed!tirclls OR LINER(if llcable
Aqua Drill, Inc. rl FROM TO DIAMETER THICKNESS MATERIAL
q ls11i1. 6 ft. L rt. L t� - in.
Company Name 4"i1.3i + 'tn ���t10i1
MIN�� 16:INNER CASING OR TUBING geothermal closed-too '
2.Well Construction Permit#:,FRCc7( ?-O-Loo -I FROM TO D1A31ETER 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): tt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_
[cultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.:
IndustriaUCommercial Residential Water Supply(shared)
1R:GROUT.
hTl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring QRecovery
injection Well:
Aquifer Rcchargc [3Groundwatcr Remcdiation 19.SAND/GRAVEL PACK(if n licable
Aquifer Storage and Recovery [3Salinity Bauer FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13StormwaterDrainage tt. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary).
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soil/rock type,grain sizc etc
Ct a. S R.
4.Date Well(s)Completed:3-to-Z I Well ID# S,
Sa.Well Locations ^ ,��` 730 ft. (,10
a. ft. '
T v �V, e K_QsleJ '� L/0 ft. J?gSft.
Facility/Owner Name Facility ID#(if applicable)
/Sm3 51��QIc RI)
�;,... Physical Address,City,and Zip
ft. ft.
So flol-s 1
21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W I lS TIO•-Z)
n
6.Is(are)the well(s)GOermanent or OTemporary Signature of-Certified WaMon r Date
By signing this form,I hereby certify that the well(s)w•as(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or with 15A NCAC 02C.0100 or ISA rVCAC 02C.0200 Well Construction Standards and that a
ff this is a repair,fill Wtt known well consnuc•tion inl'itnation and explain the nature e#'the copy of this 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:
S.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-I is needed. Indicate TOTAL NUMBER of well., construction details. You may also attach additional pages if necessary.
drilled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3135 (ff.) 24a. For All Wells: Submit this form Within 30 days of completion of well
For multiple wells list all depths ifdifjew ent(example-3L200 and 2@100') construction to the following:
10.Static water level below top of casing: 36 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 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: r'Dr r
h �, 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
13a.Yield(gpm) L Method of test: Tin.t 24c.For Water Supply&Injection Wells: hi addition to sending the form to
the address(es) above, also submit one copy of this forth within 30 days of
13b.Disinfection type: Amount: completion of well construction to Ahe 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