GW1--07830_Well Construction - GW1_20231208

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WELL CONSTRUCTION RECORD(GW-1) For Internal Ust Only:
1.Well Contractor Information:
Cameron•Bazin. •14.WATER ZONES -- • :... -
- ' ' :FROM - .TO • -. - .DESCRIPTION •.,-_ _. _ .
WellContractor Name
4518=A ft. 225 ft. 10 GPM •• .
ft _.. ft: • i
NC Well'Contractor Certification Number
• 15..OUTER CASING'(for multi-eased vells)'OR LINER(Wait lieable). - '
:Aqua Drill, Inc. FROM TO DIAMETER THICKNESS'' _MATERIAL
Company Name • :s; • • . . PVC' • '
rt: 80 ft. to.
•
. : 2,Well Construction Permit#: 499• .: - IINNER CASING DIA11GiETERhermal THICKNESS.. .. .MATERIAL:.
OR
•
List ail applicable Well.coistructionpennies(l.e.UIC County,State,,Varance,etc.) ' ' fit• . '• ft.•' .• • ' ' : iri, •'
3,Well.Use(check Well use):" . fit. fir: tn.
Water Stipply'Well: .. . _ • . . . . 17:SCREEN, .
• FROM •. TO • •DIAMETER' •.SLOT SIZE.• THICKNESS.- MATERIAL. ''
. ©Agriculttual • Ill Municipel/Public tr. fit,' . ' to
. ©Geothermal(Heating/Cooling Supply) Residential Water Supply(single) : • it. ' . . ft:: . • in. ' '•• • •
.-C Industrial/Commercial L-PResidential Water Supply(shared) =
18.GROUT
irrigation • . " FROM •TO • 'MATERIAL • EMPLACEMENT METHOD&AMOUNT.
. Non Water Supply Well: . . ' • .. . ' ' . .. ' .. . - ' , :0:.. `fit.: •27 fir:-. . . - - . . .
.�C 119onitorin � � �� � Chips,.. :.Poured
g'. . . .. • ' . .. • EDRecovery. . - : ..
Injection Well: • fit. tt: '
�QAquifer Recharge • ' (II Groundwater,RRcmcdiation •• • - -
' L•9lAqurfer,Storage and Recovery: - OC Salinity Barrier . FROM D/GRTO L PACK•MATERif IAL ' • EMPLACEMENT METHOD
.'DC Aquifer Test • • . •L:f Stormivater D ainage fit
C Experimental Technology . . DISubsidence Control ft.: :ft. : .
. ' Geothermal(Closed Loop) • • , " • J Tracer • 20,DRILLING LOG'(attach•additionalsheetsif accessary)
C Geothermal(Heating/Coo'ling Return)' '_i�C Other(explain under#21"Remarks) EOM. . T°' DESCRtrrt°N( Iar:>,antaesz sowrocu erpe:Rr�ta atze:e<o>-
0 . • ".:70, fit," . sand'.
30/23 •.4:Date Well(s)Completed: 11.13. . • . Well ID# 70 265 - ft.. '
•
rock
5a Well Location: • ft. ft. • - . ,_ .;j ,.e.. _`'? i.a" .. ."
. Edmund.Wihee . - . • fit. = , ;
Facility/Owner%tile Facility lD#(if applicable) fit'• ' h• ' ' :G. Q 0 �^ '
322 Layell'Rd Elkin,,NC rtt. rt . Iflic;;,^..;. ,.,;r;.,:,
• Physical Address,City:and Zip : -- . . • .ft." . • ft. . ' .G•.;.,�,. -. :-:.: .i'•hi.1
Wilkes : - 21:.REMARKS... - :
County .• Parcel'IdentifcationNo.(PIN)- .. ,
5b:Latitude and longitude in degrees/minutes/seconds or decimal degrees _ .
(if well field,one let/long is sufficient) - " ' • ' •22.'Certification• ' '
36:30736 N 80;93485 :. . W
1'1/30/23.
6.Is(are)the wells) Permanent or QIC Temporary Signature of Certified Well Contractor : -' •' ' Date' -
By signing this Ann,I hereby Ce7tfy thai.the well(;r)was(lure),constructed in'accordance
7.Is this a;repair to an existing well IYes or-DNo. with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 IVell Construction Standards and that a
• If i/iis is a repair,fill out known well construcllon information and explain the nature of the copy of this record has been provided to the well whet. ' '
repair under PI remarks section or on the back of thli form.
23.Site diagram or"additional well details: .
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the.sante 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:'265 • (fit.)
For multiple wells'list all depths lfdlffere i(example-3 n 00'and 2@l00') 24a..For"All Wells: Submit this form within•30 days of'completion of well
constriction to the following: '
10.Static Water level below top-of casing: 40 (ft.) Division of Water Resources,-loformation Processing Unit,
['water level is above casing,rcre''+^ 1617 Mail Service Center,.Raleigh;NC 27699-1617 '
• 11.Borehole diameter: 6. . - .. (in.) 24b.For Infection Wells: In addition to sending.the form to the address in 24a
12.Well construction method:. Rotary above,also submit one copy of this form'within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) - construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER'SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636' -
13a.Yield(gpm)-.10 Method of test: sight 24c.For Water-Supply&-Infection-Wells: In addition,to sending the form.to
HTH the addresses) above; also submit one copy of this form within.30 days of
13b.Disinfection-type Amount .160Z completion of well construction to the county health department'of the county '
where constructed. I '
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource; Revised 2-22=2016