GW1--00758_Well Construction - GW1_20240131

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: `
1.Well Contractor Information: f
Cameron Bazin 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 400 ft. ft. 1 Pint 1
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER ! THICKNESS MATERIAL
0 ft. 65 ft. 6 ! in. PVC
Company Name
018793 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER . THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. : in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO _ DIAMETER' SLOT SIZE THICKNESS MATERIAL
II Agricultural DMunicipal/Public ft ft. in.
©Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ' ft. - in,'
ID Industrial/Commercial DC Residential Water.Supply(shared) 18.GROUT 1
Il1rrigation FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 24 ft' Chips ' ' Poured
°Monitoring )D Recovery ft. ft. .
Injection Well:
ft. ft.
QAquifer Recharge In Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
El Aquifer Storage and Recovery ()Salinity Barrier FROM TO , MATERIAL EMPLACEMENT METHOD
°C Aquifer Test EC Stormwater Drainage ft. ft.
In Experimental Technology °Subsidence Control ft. ft.
i.
0 Geothermal(Closed Loop) °C Tracer 20.DRILLING LOG(attach additional sheets if necessary)
III Geothermal(Heating/Cooling Return) [ Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.)
0 ft• 55 ft• sand ,,r
12/18/23
4.Date Well(s)Completed: Well ID# 55 ft. 505 ft. rock ire? e
ft. ft. V ,,J ,l:, i-, r t"'
5a.Well Location: l t .,,°`' LC r� a, r•-•v
Jeffery Goda ft. ft. . J4N
-Facility/Owner Name Facility ID#(if applicable) ft. ft. 1 ` ���
3820 Shacktown rd Yadkinville, NC ft. ft. 'r" ^n ''"
`
Physical Address,City,and Zip
ft. ft. ; : L1,�j
Yadkin 21.REMARKS
County Parcel Identification No.(PIN) i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.12057 N 80.55025 W
t'_ ,-, i 12/18/23
6.Is(are)the well(s)OPermanent or ❑IC Temporary Signature of Certified Well Contractor ! Date
I
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or ©No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well 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 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: 805 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following: j
10.Static water level below top of casing: 1 00 (ft.) Division of Water Res iurces,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.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
1 Pint Bucket '
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also subtnif one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 320Z completion of well construction ito 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