GW1-2021-04634_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: .-.
Nathan Seagie ,;'°e; �V 14.IVATERZONEs E
Well Contractor Name q y'-° FROM TO DESCRIPTION
4499-A AY 1 4 2021 Z frft Z So ft.
NC Well Contractor Certification Number „!�Ogq;Ie UYZi) r
-is.OUTER CASING"for inulti-cnsed wells OR LINER ifa licable
Aqua Drill, Inc. y�P Y;Q(1 FROM TO DIAMETER THICKNESS MATERIAL
" t7 ft. p it. in.
Company Name
MANNER CASING OR TUBING geothermal closed-loo
2.Well Construction Permit#: FROM I TO I D(A31ETER THICKNESS I MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. I ft. in.
3.Weil Use(check well use): ft' I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DiADrETER SLOT SIZE THICKNESS MATERIAL
-)Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidentiai Water Supply(single) ft, ft, in,
Industrial/Commercial Residential Water Supply(shared) i8:GROUT
hri at1011 FROM TO MATERIAL ";+-EMPLACEMENT METROD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ORecovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge [3Groundwatcr Rcmcdiation 19,SAND/CRAV.EL PACK lif applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology E3 Subsidence Control
Geothermal(Closed Loop) Tracer `20:DRILLING LOG attach additi6nalshects if necessary
Geothermal eatin Cooling Return n Other(explain[order#21 Remarks) FROM TO DESCRrPTiON color,hardness solltmck type,grain size etc
ft. ft.
4.Date Well(s)Completed://-4-7 Well ID# ft. Iva
ft.
ft, ft.
5a.Well Location: G
Facility/Owner Name Facility ID#(if applicable)
Physical Address,City,and Zip
�L 7/ ZSOd J!$g Sb 21.REMARKS.
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 . y'I-Z rYc
6.Is(are)the well(s) rmanent or Temporary Signature o Certified_a oreerlifi,
Date
By signing this form.I her; that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well Yes or �N0 with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthiv iv it repair,fill out known well commuction information and explain the nature of the cape of this record has been provided to the xv/1 owner.
repair under#21 remarks section or on the back of this form.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also'attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 Z 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferem(example-3@200'and 2@V 001 construction to the following:
10.Static water lei ei below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfvvater level is above casing,use"+^l 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: fo (in.) 24b.For Iniection 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: Ar ��,�%/ 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) J Method of test:GIOrL} �.M e 24c.For Water Supply&Iniection 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: IfZ/l Amount' ?lsCZ 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