GW1-2021-00355_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CAMERON BAZIN 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I
A - 4518 ft. n.
NC Well Contractor Certification Number 15.OUTER CASING for.multi-cased wells OR 11:LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER! FTHICKNESS
MATERIAL
ft. I ft. in.
Company Name
.16.INNER CASING OR TUBING eothermal closed-loop
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 28.0 ri- 2.0 "' I SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 28.0 ft. 48.0 ft• 2.0 1O" .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fit- 23.0 ft• PORTLAND aENTONITE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well: rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 26.0 ft- 48.0 rt• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence 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,soiltmck type, min size,etc.
0.0 ft. 38.0 1" CLAY
4.Date Well(s)Completed: 01/19/21 Well ID# MW-5 38.0 ft- 43.0 ft- PWR
5a.Well Location: 43.0 ft' 48.0 ft. ROCK
RAYS CLEANERS ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
1558 NORTH BRIDGE STREET ELKIN 28621 ft. ft.
Physical Address,City,and Zip
n. ft.
SURRY 21.REMARKS
BENTONITE SEAL-23.0-26.0 FEET
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
360 16' 21.29" N 800 51' 09.71" W 1/20/2021
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the ivell(s)seas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!5No ISA NCAC 02C.0100 or 15A NCAC 02C,.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction information and explain the naiure;ofyltie`t +ofthis record has been provided to the well owner.
0
repair under#21 remarks section or on the back ofthis form. g+'^l f •'
y 23.Site diagram or additional well details:
i ay use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same - 'j�
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of $f� �j 'tQC1p,ee Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: Jr` 24.'SUBMITTALINSTRUCTIONS
9.Total well depth below land surface: 48.0
1-'or multiple wells list a//depths ifdierew(example-3 a 200'and 2 a@100') S;. Submit this GW-I within 30 days of well completion per the following:
30.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
]0.Static water level below top of casing: (ft.)/J'svater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
6.0 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of thecounty where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,RaleighsNC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources j' Revised 6-6-2018