GW1--05852_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
685 rt• rt. t gym
4518-A
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 68 ft. 6 in. PVC
Company Name
017472 16.INNER CASING OR TURING(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): ft. ft. n.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
D Agricultural Municipal/Public ft. ft. in.
a Geothermal(Heating/Cooling Supply) (°Residential Water Supply(single) ft ft. in.
°C Industrial/Commercial DC Residential Water Supply(shared) 18.GROUT
11 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 25 ft• Chips Poured
0Monitoring ©Recovery ft. ft.
injection Well:
ft. ft.
°Aquifer Recharge II Groundwater Remediation
• 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery °C Salinity Barrier , FROM TO MATERIAI. EMPLACEMENT METHOD
°C Aquifer Test °C Stormwater Drainage ft. ft.
•
@Experimental Technology 0 Subsidence Control ft. ft.
°Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIP'ION'color,hardness,soil/rock type,grain d>r,etc.)
°Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 60 ft. sand
4.Date Well(s)Completed: 9/16/24 Well ID# 60 ft. 605 ft' rock
ft. ft. ' 1
5a.Well Location: 1 �✓
Robert Rhodes ft. _ ft. O . ti ! 2fl24
Facility/Owner Name Facility ID#(if applicable.) ft. ft.
Fairground rd East bend, NC ft. ; ft. r
Physical Address.City.and Zip ft. ft.
Yadkin 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.21854 N 80.51396 W (3c— 9/16/24
6.Is(are)the well(s)JPermanent or °Temporary Signature of Certified Well Contractor Date.
By signing this form, i hereby certifit the t the well(s)was(were/constructed in accordance
7.Is this a repair to an existing well: jp Yes or °No with iSA NCAC 02C 0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction in/orrnutian and explain the nature of the caps of this record has been provided to the veil owner_
repair under#21 remarks section or on the buck of this form.
23.Site diagram or additional well details:
S.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: 805 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if-different different(example-3(1000'and 2(a)!00') 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
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 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
13h.Disinfection type: HTH Amount: 160Z completion of well construction to the county health department of the county
where constructed.
Porn(iW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016