GW1--01592_Well Construction - GW1_20240308

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WELL CONSTRUCTION RECORD(GW-1) .' For Internal Use Only: •
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1:Well Contractor Information: •
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• Cameron Bazin . • 14.WATERZONES
Well Contractor Name .FROM .' ., .TO - 'DESCRIPTION . . . . . '
5fi5 ft•. ft. 75gpm
4518-A
ft ft..
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable) •
Aqua Drill, Inc. -- - -- FROM - -TO.. DIAMETER..' •THICKNESS MATERIAL
0 - ft 55 ft. (i i'in. PVC
Company Name - • '
4 0 - -16.INNER CASING OR TUBING(geothermal closed-loop) '
2.Well Construction Permit#: .�98 'FROM . ' TO - . •DIAMETER . 'THICKNESS ' •MATERIAL
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List all applicable well construction permits(i.er UIC,County,State,Variance;etc) : ft..; : ft. in. ' . •
' 3.Well'Use(check well use): • ft. ft. -, in..
Water Supply Well: SCREEN- • , FROMTO DIAMETER SLOT SIZE THICKNESS . MATERIAL '
' ill Agricultural • I.C Municipal/Public ' ft. ' • ft. ' in•
n Geothermal(Heating/Cooling Supply) • WResidential•Water Supply.(single) fa. ft: iu.:
jd Industrial/Commercial • Residential Water Supply(shared) 18.GROUT
E Irrigation' -. . FROM TO - • :MATERIAL EMPLACEMENT METHOD&AMOUNT
-. .Non-Water Supply Well: •0 'ft;.: 25 •ft' . Chips'. Poured
Monitoring C Recovery ft '. ft..
Injection Well:
• ft.. ' - ft.
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Aquifer Recharge . . . -QGroundwater Remediation • - - ' . . '
19.SAND/GRAVEL PACK(if applicable)
fjiAquifer Storage and Recovery ' ,flSalinityBarrier • , FROM. .TO . MATERIAL . . . EMPLACEMENT METHOD . •
E Aquifer Test . 'Q'Stormwater Drainage ft.• ;• ft.
- 711 Experimental Technology . `,E Subsidence Control. . ft:. ft. . • •
Geothermal,(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
' FROM - • TO ' • DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
-I Geothermal(Heating/Cooling Return) ' i-C Other(explain under'#21•Remarks)
: .0: ft.: : '45' ft. .sand , •
4.Date Well(s)Completed: 2/20/24 •Well ID# - ' 45 ft ft'• 585 • • rock ,
Sa.Well Location: ft.- : ft. 6•` ,-. f 1'1 •
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Patsy London f`. ft' . : A�„„ '�-
Facility/Owner Name - Facility ID#(if applicable) ft ft.- IVIH �• GUL4
9030 Moore rd Tobacco ville,':NC ft.: . ft.
- _ Physical Address,City,and Zip ft: ft. �d9QI, , '`e
Forsyth 21.REMARKS
•County. '. 'Parcel Identification No.(PIN) '
511 Latitude and longitude in degrees/minutes/seconds-or decimal degrees: " . ' '
(if well field,one lat/long is sufficient) - 22.Certification:'. . . . '
36.24294 . . N 80:34350' w
L ,2 2/20/24
- 6.Is(are)the well(s)$Permanent 'or.[IC Temporary Signature ofCertified'Well Contractor Date
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. • By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
. 7.Is this a repair to an existing well: ©[Yes or•0No. • • with 15A NCAC 02C i0100 or 1.5.4 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 1/21 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: 585 ' •(ft.) 24a. For:All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfderent(example-.3@200'and 2@I00') - 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
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11.Borehole diameter:'.6 (in.) 24b:For Iniection.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)-75 Method of test: sight• 24e.For Water Supply&Injection Wells: In-addition to sending the form•to,
the.address(es) above, also submitlone copy of this forth within 30 days of.
HTH" 160Z
13b.Disinfection type: . ' 'Amount: 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