GW1--05944_Well Construction - GW1_20241009

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: L.. .'�'
1.Well Contractor Information:
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Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 445 ft. ft' 2 Gpm
• ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 70 it. 6 in. PVC
2266 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,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
Agricultural I 1 Mu FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
nicipal/Public ft. ft. in.
El Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in.
MI Industrial/Comutcrcial °C Residential Water Supply(shared) -
18.GROUT
!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 25 ft. Chips Poured
it]!Monitoring JRccovcry ft. ft.
Injection Well:
A uifer Recharge ft. ft.
9 � g �Groundwater Remediation
[�Aquifer Storage and Recovery C SalinityBarrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
IIiAquifer Test 0 Stormwater Drainage ft. ft.
MI Experimental Technology _:P t�,Subsidence Control ft. ft.
)fiGeothermal(Closed Loop) l?.S°'Tracer 20.DRILLING LOG(attach additional sheets if necessary)
iU Geothermal(Heating/Cooling Return) f�)C Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soi0rnck type gain size etc)
0 ft. 60 ft• sand
4.Date Well(s)Completed: 9/19/24 Well ID# 60 ft. 505 ft.
rock
5a.Well Location: ft. ft.
CMH ft. ft.
:
Facility/Owner Name Facility iD#(if applicable) It, ft.
7883 NC 268 Dobson, NC ft. ft. UL i 0 5 2024
Physical Address.City,and Zip ft. ft.
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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:
36.32738 N 80.72386 W
Caerw_ref_f' 9/19/24
6.Is(are)the well(s)IPermanent or O Temporary Signature ofCcrtificd Well Contractor Date
By signing this form I hereby certin'that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: I Yes or EtNo with ISA NCAC 02C.0100 or ISA NCAC 02C.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 has been provided to the well owner.
repair under#21 remarks section or on the back of this forni.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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
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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 ffdifjerent(example-3@ 200'and 2@100') 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
12.Well construction method: Rotary • above,also submit one copy of this form within 30 days of completion of well
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) 2 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
13b.Disinfection type: HTH Amount: 160Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016