GW1--01550_Well Construction - GW1_20240308

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: •.
.
Cameron Bazin 14.WATER ZONES
We1lContractorName FROM . TO DESCRIPTION •
'
•425 ft._ ft. 1l2 GPM -
4518-A ft rt..'. .
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. 30 • ft.'•' 6 I . in. . PVC
Company Name ' •
018580 •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): dt ft. • in..
1 ater Supply Well: 17.SCREEN
PP y FROM . . TO DIAMETER SLOT SIZE '. THICKNESS . MATERIAL
C Agricultural ••©C Municipal/Public ft. ft: in.
C Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft.. ft. ;u,'
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
1Irrigation . . - FROM TO' ' :MATERIAL : '• EMPLACEMENT METHOD•&AMOUNT'
Non-Water Supply Well• . -0 ft 22 'ft . .Chips; `Poured".
[Monitorin •g
WelRech ©C Recovery .Groundwater Remediation ft. ft:. .
Injection l:arge
ft, ', ft. ' j
C Aquifer •
.19.SAND/GRAVEL PACK(if applicable)
I C Aquifer Storage and Recovery .[Salinity Barrier .FROM. . .TO . ' MATERIAL . . . EMPLACEMENT.METHOD .
_C'Aquifer Test I�.L Stormwater Drainage ft. ft:. .
.]Experimental Technology ®Subsidence Control ft.. ft. . . ,
' Geothermal(Closed Loop) .'Tracer' 20.DRILLING LOG(attach additional sheets if necessary) ' •
',Geothermal(Heating/Cooling Return) ' G Other(explain under#21.Remarks) FROM TO - DESCRIPTION{colon hardness,soiOrocKtype:grain size,etc.)
0 ft.: : 20: ft. sand, „_l^by 6...p 0-....
4.Date Well(s)Completed: 2/28/24' , Well m# . 20 ft . 625 ft.!' •rock n l r"' L st y I
5a.Well Location: fa ft. /i MAR 1) $ n A
Donald-taylor ft. f` rvL
. ft. rm: ina:a'n r-,;5i742ifel Lhb
Facility/Owner Name Facility ID#(if applicable) • 'ft DtVei q a u
•
4837 Wrenn Rd East bend,.NC: • ft.: ft. '
Physical Address,City,and Zip ft ft..,
Yadkin . •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:
36.15613 N 80.48888 •
W
6L 2/28/24
6.Is(are)the well(s)JPermanent or.0Temporary Signature of Certified Well Contractor + Date
By signing this form,I hereby certifir that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well:.. ®C Yes or ljNo with 15A NCAC 02C.0100 or 15A 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: 625• (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths.ifdderent(example-:3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,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
(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) 1/2 Method of test: Bucket • 24c.For.Water Supply&Injection 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources - • -Revised 2-22-2016