GW1--05673_Well Construction - GW1_20240920

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WELL CONSTRUCTION RECORD(GW-1) For -liPrint Form
Internal Use Only: `' j •
1.Well Contractor Information: i
I 1
Cameron Bazin ;
• 14.:WATER ZONES
Well Contractor Name FROM. TO DESCRIPTION
- - _ -
4518-A 245 it B• 20 gpm
NC Well Contractor Certification Number ft. ft.
I. ,
Aqua Drill, Inc. -1S.'oUTER CAsINC(for multi-casedwells)°RIMER plan IIceble), . -
FROM' TO DIAMETER THICKNESS, MATERIAL
Company Name 0 R• 1100 ft' I 6 , in' I PVC
327.3 -16.INNER.CASING OR TUBING(seotbermal elosed400p)__ _
2.Well Construction Permit it': FROM To: DIAMETER' rm CIMESS List all applicable well construction permits(i.e.WC,Caunry,State,.Variance,etc.) R. ft. in. MATERIAL
3.Well Use(check well use): ft. ft. hi. -
Water Supply Well: 17:SCREEN
"-' 1. �MUntClpal/POb]iC -FROM, TO -DIAMETER SLOT SIZE THICKNESS MATERIAL
R. R. in.'
I©Geothermal
(Heating/Cooling SnPP1Y) Residential Water Supply(single)
o[lndustriaYCommercial R. in.
�[Residential Water Supply(shared) -
hC Irrigation. 18 GROUT _
FROM TO, MATERIAL EMPLACEMENT METHOD Si AMOUNT
Non-Water Supply Well: - 0 24
�[Monitoring. [Recov Chips Poured
Injection Well: ft. R•
[Aquifer Recharge QGroundwaterRcmediation
Aquifer Storage and ..19.:SAND/GRAVEL,PACK _---
Y ElSalinityBarrier .MATERIALe)•
FROM. "TO MATERIAL ENPLACEMENI,Hy1gOD
Aquifer Test °[Storm =Drainage R•
ft-
MExperimental Technology iliSubsidence Control
R it; ,
jGeothexnial(Closed Loop) DTracer 20..DRILLING'LOG fatted:additional,ehccte'';ifnece
ssary). .
rig Geothermal(Heating/CoolingReturn) EiOther(explain under#21Remadts),, FROM. TO DESCRIPfmcolor,hardness,so0noekt7e.kraln size.
ete)
4/19/24 0 R' 80ft• sand ' •
4.Date Well(s)Completed: Well ID# 90 385 R•
rock i : ^..-. b.
0, ft.Well Location: '.
CMH homes, , e. `'° C.'°4;....4 �� ""a
Facility/Owner Name Facility lD#(if applicable) R. ft. �� P2 2024
137 Iron horse trl Ararat, NC 2700 •
7
Physical Address,City,.andZip [t. ft. lr1i;/:pCI:Cil r•rrn404'.`-,C11}s
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Surry 2L':REMARK$'
County Parcel Identification NO.(MO
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /
(if well field,one'latllong is sufficient)
2236.37097 •
N 80.58195 •EertiB •
eation:
W C'rt.r ^ — 4/19/24
6.Is(are)the we0(s)OPermanent or EgTemparary Signature of Certified Well Contractor .
Date
7.Is this a repair to an existing well: [Dyes or °No twihsSANCAthiC 02C.0l00eo ISA by N aC 02C.02hat ihe 00)was Wdl onr ucotion constructed
aid Iha cc
If lids ire repair,Jill out!moron Ivesconstrucllo,,information and explain the nature of the ropy efthls record has been prwtdedle the wal/ouner.
repair wider#2/remarks section orou the back of this form.
23.Site diagram or additional well details:
it.For GeoprobejDPT or Closed4.00p Geothermal Wells having the same You may use the back of this page to;provide additional well site-details or well
construction,only 1 OW-I is•needed: Indicate TOTAL NUMBER of wells• construction details. You may also attach•additionai drilled: pages if necessary.
SUBMITTAL INSTRUCTIONS '
4.Total well.depth below land surface: 385 (ft) - ,
Fortnalitple wells,list all depths ifdlare it(example.3@200'and 2@l00� For All Wells: Submit this form within 30 days of completion of well
constrmction tO the:following: 1' •
10.Static water level below top of casing 40 O
$waterlerzl is above casing use"+-
Division of Water Resoerce,.Information Processing Unit,
1617 Mail'Sertdce Center;Raleigh,NC 27699-1617
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11.Borehole diameter. 6 (in.) pp
24b.For Infection Wells: In additionf tol 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
lie.auger,rotary,cable,direct push,eta) construction to the-following:
Division of Water Resources,Und ergroun NC tion Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail,Service Center,
,Raleigh,NC 276994636
13a.Yield(gpm) 20 Method of test: sight 24e.For Water.Sumnly&.Infection Wells: In addition to sending the form to
13b.DishlPection type: i III i Amount 160Z the addresses) above, also submit one 'copy of this form within 30 days of
• completion of well construction to the!county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources !
Revised 2-22d016