GW1--05853_Well Construction - GW1_20241001

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 450 ft. ft. 1 gpm -
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap Heable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft 65 ft. 6 in. PVC
020134 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable%sell construction permits(i.e. U/C,County.Stale, Variance,etc.) ft. ft. in. '
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
4gricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single)
ft. ft. in.
= IndustrialiCommcrcial 0Residential Water Supply(shared) -
18.GROUT
E. Imgation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 22 ft. Chips Poured
_ Monitoring 0Recovery ft. ft.
Injection Well:
ft. ft.
=Aquifer Recharge ®Groundwater Remediation
uifer Storage and Recovery19.SAND/GRAVEL PACKOfapplicable)
•A
q 0C Salinity Barrier FROM ' TO MATERIAL EMPLACEMENT NtETHOD
Aquifer Test 0 Stonnwater Drainage ft. ft.
Experimental Technology QC Subsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) !Other(explain under d21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain alai:,etc.)
0 ft. 55 ft. sand
4.Date Well(s)Completed: 8/26/24 Well ID# 55 ft. 505 ft.
rock ,_ a =` I,w><.,.
5a.Well Location: ft. ft.
James Mcbride ft. rt. OCT o ! 707
FaciitgOwner Name Facility lD#(if applicable) ft. ft.
Appaloosa dr Eastbend, NC ft. ft.
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(at,long is sufficient) 22.Certification:
36.19672 80.46047
NW ^ (301_ 8/26/24
()Temporary
Signature of Certified Well Contractor Date
6.Is(are)the well(s)DPermanent or
By signing this Arm, l hereby ceniu i that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 11 Yes or QNo with ISA NCAC 02C 0100 or ISA NCAC 0.2C.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 hue been provided to the well owner.
repair under'421 remarks section or on the buck of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-I 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: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it dijjerent(example-3(0200.and 20.1 l00')
construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
1/miter 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
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:
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: Bucket 24c.For Water Supply& Injection Wells: In addition to sending the form to
the addresses) 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.
Puna C\\-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2(116