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Home My WebLink AboutGW1--02727_Well Construction - GW1_20240507 �. Print Forni 'WELL CONSTRUCTION'RECORD(GW-1) • - - For Internal Use Only:" : : • 1.Well Contractor Information: . • Cameron:Bazin- 14.WATERZONES i • ' ' • Well Contractor Name •. .. --- • • • FROM TO'• - DESCRIPTION 45:18-A; :286... ft'" . : • .' ft' : .•2o gpM f . •. .. . " • : . ff ff. NC Well Contraetor•Certification Number - 15 OUTER CASING(for m_ulti-cased!wells)OR LINER{if ap•llcable) • -- - . • Aqua brill,:Inc.: - . . ' . , . -FROM. . ' .TO• • •. DIAMETER. THICKNESS .MATERIAL . . . • ' - " .. . ,, . , - p- ft. 120-' ft:. ;.6 _ :!,;In.• . PVC . CompanyName 3824 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,eta)' .. . ; ft ft. ln.• . . -. 3.Well Use(check well user : f6 , ' ft ia. - 17:SCREEN••. , Water Supply Well:'• • • • FROM ' TO' . • DIAMETER' SLOT SIZE 'THICKNESS. •MATERIAL QAgricultural'- . . • ; • . QMunicipal/Public : ' -• ' '..ft.• 'ft.. • . . •in.- • • ' . .. . 1111 Geothermal(Heating/Cooling Supply) Residential Water Supply(single).: . •ft: , •ft: •:. in ,. • . . , DIndustiial/Commercial . :: - ' : QResidential Water Supply(shared) 18.GROUT ' ' ILlirrigafion- - - . • _ • .FROM. . • TO ' ' MATERIAL. ' EMPLACEMENT METHOD&AMOUNT •. •" . : : . Non-Water Supply Well:: •• .0 • .. ' .22: • : • ' Chips ' Poured'' . ' . • ' ..,' .• . .' . • ft— • '::oMonitoring. , . :: Recovery " • .. . , ft. ft. '. . ' Injection Well• ill Aquifer Recharge , . - QGroundwater Remediation.• - ' • - ' '" ' _ QC 19.SAND/GRAVEL PACK(if applicable). " Aquifer'Storage and Recovery: Salinity Barrier .FROM TO. • . . MATERIAL EMPLACEMENT METHOD • -. j�Aquifer:Test..• • • :'- QStormwater Drainage.... : ' ft; fa ! _ . : _ : . . l Experimental Technology •': . • . 1g Subsidence Control .. . ' :rt.' .fi.. ::•: • ' . .'. :. j�Geothermal(Closed Loop) ,.. :.IjTraeer.. . •:: . : ' •20:DRILLING LOG(attach additional sheets If.necessary) -• :-. •'" ' ' •" FROM• TO •_ .DESCRIPTION(color,hardness,eoll/rock type,grain size,etc.)- $�Geothermal(Heating/et:whi g Return). QC Other(explain under#t21-Remarks) nd 4/22/24- ' 4:Date Well(s)Completed:• •- ' Well DU. - . " :110 f "325 • ' rock • .. 5a.Well Location: : t4 k • j::' CMH homes to . ; Facility/Owner Name . -.. -': : Facility ID#(if applicable) ' ; . •.: ft : • ',: 1.045 haystack-rd MT airy,:NC :" rr.: ft.• H : Physical Address;City,and-Zip' - ft. . • ft. ' r Z' .,.:k.,,•K..:i u•I I ., 21:REMARKS . • i^- .. . ' .. County' .. . :.Parcel I No • dentification .(PIN) . • ivip�`' v � [U[4 ,5b.Latitude and longitude in de rees/minutes/seconds_or decimal de rees: • " . . 1 vi ;_. .^n c• c Grp.- , . . :. '' . . '(ifwell field;one Lit/long is.sufficient)g . . ' ; . . ' -: g ' , 22..CertifieatIon:" ' - - " l-`l'i(•:,1 iJv . . •v - • : ' • 36.46471. :.. ... • N 80.72633'.. . • w :... • - . • . 6.Is are the wells d Permanent or G Tem.ora • Signature of Certified Well Contractor - Date ' ( ) O Q P Iy, ' ;..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: II Yes or til No" • with,15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a- Ifthis 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 Oeoprobe/D—Pr 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 - ' . •constiuction.details.,You may also attach additional pages if necessary... • • • - -' .: '.. '. . •".SUBMITTAL INSTRUCTIO - 9.Total:well depth below land surface: 325 . . ; :' :(ft) P :24a. For All'Wells: Submit tiffs form within 30 days of completion of well , For phltiplC wells list all depths if different(example-3 200"and 20100' ' : : construction to the;following: ' . • • • • • 10.Static water level below top of casing: 40 (ft) - Division of Water Resources,Information Processing Unit, : Ifwaterievel is above casing'use"+" . •- ' .. - 1617 Mail Service.Cf nter,Raleigh,NC 27699-1617 . 11.'Borehole diameter:•6 (in.). 24b.For Infection 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:. . . : •construcfion io the following: ' • (i.e.auger,rotary,cable,direct push,etc.) II- • • Division of Water Resources,Underground Injection Control Program, •. • FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service.Center,Raleigh,NC 27699-1636 1.3a.Yield(gpm) 20 • • . :Method of test: sight ' •• • 24c:-For W ;W'water Supply&Inlecti Deils: In addition.to sending the fora 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. 1 Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, , Revised 2-22-2016 i