GW1--02490_Well Construction - GW1_20240423

-Print Form
• - - WELL CONSTRUCTION RECORD(GW-1) . .• - • For Internal Use Only:- -- - ' . • .
• 1.Well Contractor Information:
Cameron.Bazin .. 14.WATER ZONES.:
Well Contractor Name ' ' - FROM TO'• -;DESCRIPTION - -
4518-A 186: ft . .-ft ,'spm I. I
. •• ft.. • : . ft.. ,.. .• .
NC Well Contractor Certification Number, '' 15:OUTER CASING(for multi-cased wells)OR LINER(if ap"livable) •- - -
- Aqua Drill, Inc.." • •• • :FROM. . .TO DIAMETER. THICKNESS MATERIAL
. .0 ' . ft' 30 fit: :6 . .'in. -: ' .. .PVC
. CompanyName •
018666 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): • . f' • .ft : ' . In.' :
: WaterSupply Well: -17:SCREEN _ D :-. .. •: N '
. . FROM ' TO - DIAMETER' SLOT SIZE THICKNESS. MATERIAL
•
• to Agricultural . Ill Municipal/Public . • • .ft ft.. •in. • • •
. n Geothermal(Heating/Cooling Supply) LjttesiOntial Water Supply(single) , fit tt in•
Indus.trial/Commercial QResidential-Water Supply(shared) , •18.GROUT'
C Irrigation• . " . • ' . FROM . • .TO ' . _ MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non=Water Supply Well:: • . • '• . : •• • 0 it 21• : it• Chips Poured • -
' • lid Monitoring. • . QRecovery. tt tt
• .Injection'Well:
' II Aquifer Recharge :[3 Groundwater Remediation ' - ' " •
19.SAND/GRAVEL PACK Of applicable) •: .
IliAquifer.Storage and Recovery 0 Salinity Barrier .: .FROM TO. MATERIAL ' . EMPLACEMENT METHOD
NI Aquifer Test' • 0 Stormwater Drainage . . : " ft: ,ft, • , : ._ • -
. id Experimental Technology • 0Subsidence Control • '. ft. ' -ft. " : : - .
. Ill Geothermal(Closed Loop)' .. .0 Tracer... . . ... .• •20.DRILLING LOG(attach additional sheets if necessary) .• ,- " - . . " - .
FROM• ' TO .DESCRIPTION(calor,hardness,soWrock type,grain size,etc.) ..
• C Geothermal(Heating/Cooling Return)" C Other(explain under#21 Remarks) 1
• - ••0 n-' .20 ..••ft• sand .
• 4:Date Wells " • 4/9/24 Well ID# - : . 20 ft': ..225 .fit . -
()Completed: 'rock:.
• . ' 5a.Well Location: • fit it .-
- Bryan Watson ft. ft . .. .. .i ` .
' Facility/Owner Name . ' ' - . Facility,ID#(if applicable) fq ft n D D O r
2202 Seagraves rd Harnptonville, NC • ft. :ft. t tG2 •
' Physical Address,City,and Zip •
- Yadkin • .. . . 21:REMARKS • .., l c J',_h ' •_ . : . ,
County Parcel Identification No,.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: :
(if well field;one lit/long is.sufficient) • ' ' - 22.Certification: •• • ' •
• 36.09958 . N 80.805 •
it.--..—• 4/9/24 . .
6.Is(are)the well(s) Permanent or D Temporary Signature of Certified Well Contractor Date
. By signing this form;I hereby certif,that the well(s)was(were)constructed in accordance .
7.Is this a repair to an existing well: C Yes or FNo' . 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 i 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: 225 . (ft.) 24a. For All Wells: .Submit this form within 30 days'of completion of well
For multiple wells list all depths if different(example 3@200'and 2@l00') • construction the,following:
• 10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing.Unit, _
• !fleeter-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
13a.Yield(gpm) .1 0 - _-Method of test: Sight 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