GW1--02552_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: .Print Form
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1.Well Contractor Information:
Cameron Bazin i
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14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
4518-A 385 ft. ft. 3 gpm i ;
NC Well Contractor Certification Number ft. ft.
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)ORLINER'(ifap !feeble)
FROM TO DIAMETER THICKNESS MATERIAL.
Company Name 0 ft. 160 ft. 1 6 in. I PVC
3984 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. I in. -
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZES THICKNESS MATERIAL.�C Municipal/Public ft. ft. in.
)d Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single)
ft. ft. in.
MI Industrial/Commercial 0C Residential Water Supply(shared)
C J Irrigation 78.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft'
iff+Monitoring C RecoveryChips Poured
Injection Well: _ ft. ft.
IR Aquifer Recharge DC GroundwaterRemediation ft. ft.
Aquifer Storage and Recovery �C Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD In Aquifer Aquifer Test D Stormwater Drainage ft. ft.
i0 Experimental Technology 0Subsidence Control ft. ft.
If Geothermal(Closed Loop) ®I Tracer 20.DRILLING LOG(attach additional sheets if necessary)
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fi Geothermal(Heating/Cooling Return) rC Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,
0 ft- 50 ft. sand'
4.Date Well(s)Completed: 4/3/24 Well ID# ft• ft
50 . 425 . rock
5a.Well Location: ft. ft.
Lisa Wright ft. ft. '
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1181 Gib Ferguson rd King, NC ft. ft. _ -
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Physical Address,City,and Zip ft. ft.
T,` �s ^i
Stokes 21.REMARKS APR n 1 In(;7/
County IdLUG r
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: n '~
. "�-�^:(]fit•;u J J,`,:.
(if well field,one IaVlong is sufficient) • 1,,`,:: "` r
22.Certification: +e'�' '�"
36.31017 N 80.29569
W �� a-l'�" 4/3/24
6.Is(are)the well(s)C3pertnanent or QTemporary Signature of Certified Well Contractor' Datc
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: .EYes or oNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Nell 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 o/ibis•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: I
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425
For multiple wells list all depths if d erent(example-3 ref 200'and?a!00') (ft') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 40 ft I,
limiter levelle above el be;use"+" ( ) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary above,also submit one copy of this form within 30 days of completion of well •
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,fUnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 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
136.Disinfection type: HTH Amount: 160Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 1
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22 201 G
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