GW1--00634_Well Construction - GW1_20240119

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: !
1.Well Contractor Information: I
Cameron Bazin -14.WATER ZONES I ,
WellContrectorName FROM TO DESCRIPTION
4518-A 225 It ft. 40 GPM 1 1
ft. rt. i 1
NC Well Contractor Cc lOcation Number _
15.OUTER CASING(for multi-cased wells)OR LINER(If applicable)
Aqua Drill, Ind. FROM TO DIAMETER 'THICKNESS ll MATERIAL
Company Name 0 ft 95' ft. 6 in. PVC
02382 16.INNER.CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO ' ' 'DIAMETER'" THICKNESS MATERIAL
List all applicable-well construction permits(le.U1C,Comp,.State.Variance,etc.) ft. ft. ,iin.
3.Well Use(check well use): ft. ft. 'In.
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Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
)d Agricultural ®Municipal/Public .ft. ft. in.
j0 Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. to
III1Industrial/Commercial °Residential Water Supply(shared) 16:GROUT
C Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 83 ft' Chips ' Poured
IA'Monitoring kJ Recovery R. IL I '
Injection Well:
MI Aquifer Recharge. i 111 Groundwater Rcmcdiation
I�iAquifer Storage and Recoveryp�SalinityBarrier 19.SAND/GRAVEL PAC&(if applicable)'
FROM TO MATERIAL I EMPLACEMENT METHOD
MiAquifer Test 0 Stormwater Drainage ft. ft.
I Experimental Technology DSubsidence Control ft. ft.
IM Geothermal(Closed Loop) °C Tracer 20.DRILLING LOG(attach additional-sheets If necessary)
Geothermal(Heating/Cooling Return) FROM TO .DESCRIPTION(color.hardness,soil/rock type,grain size.etc.)
( gl gOther(explain under=#21 Remarks) 0 ft, 80 R Sand
4.Date Well(s)Completed: 1/10/24 Well ID# - 80 ft 265 t Rock
ft. ft. 1
5a.Well Location:
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John Mills ft. ft. L;at. b y n -�
�, Ix
Facility/Owner Naino Facility ID#(if applicable) ft. ft.
733 Neal rd MT'Airy, NC ft. ft. i. JAN 1 9 ZUl4
Physical Address,City,and Zip ft. ft. Ifi90e't ;`n
sorry 21.-REMARKS CD',=.,:Tan ti ;„�"".''
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well'field,ono lat/long is sufficient) 22.Certification:
36.46441 N 80.78868 Ri
GL 1/10/24
6.Is(are)the•well(s))Permanent or C Temporary Signature of Certified Well Contractor Date
By signing this form,I herein•certify that she'nell(s)was(were)constrricted in.accordance
7.is this a repair to an existing well: DYes or )',]+ No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consulted&Standards and that a
If this is a repair,fill out bons;well construction lnfonnation and explain the nature of the copy of this record has been provided to the w;eII owner.
repair under#21 remark section or on the-back of thisfbrm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-I 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 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereni(example-3Q200'and 2Ql00) construction to the following: I'
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10.Static water level below top Of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
1/muter level is above casing,use'•+- 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
II.Borehole diameter: 6 (in.) 24b.For injection Wells: in addition to:sending the form to the address in 24a
Rotary above,also submit one copy of this form'within 30 days of completion of well
12.Well construction method: 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
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13a.Yield(gpm) 40 Method of test: sight 24c.For Water Supply&lnjection 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: HTH Amount: 160Z completion of well construction to the'county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2616
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