GW1--06354_Well Construction - GW1_20241025

WELL CONSTRUCTION RECORDGW-1 -
� � For Internal Use Only: 1------- --
1.Well Contractor Information: 1 Cameron Bazin 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
4518-/4, 185 11 .ft• 20gptn
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-eased wells)OR LiNER(if ap licable)
Aqua Drill, Inc. , FROM TO I DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 120 R. 6 in. I PVC
413276 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
ffilA cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QMunicipal/Public ft. ft. in.
III!Geothermal(Heating/Cooling Supply) Ej Residential Water Supply(single)
ft. ft. in.
MI Industrial/Commercial C Residential Water Supply(shared)
18.GROUT
C!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_Non-Water Supply Well: 0 ft• 20 ft- Chips Poured
El Monitoring ©Recovery ft. -
injection Well: ft.
!Aquifer Recharge ['Groundwater Remediation ft. ft.
mlAquifer Storage and Recovery C Salinity Barrier 19.SAND/GRAVEL PACK(if applicable) -_
FROM TO MATERIAL EMPLACEMENT METHOD
IIIAquifer Test 0 Stormwater Drainage ft. ft.
II Experimental Technology Di Subsidence Control ft. ft.
IIGeothermal(Closed Loop) C Tracer 20.DRILLING LOG(attach additional sheets if necessary)
t Geothermal(Heating/Cooling Return) ID Other Other(explain under#2l Remarks) FROM TO DESCRIPTION(rotor,hardness sail/rock t}pe,grain size etc.)
0 ft. 110 it sand
4.Date Well(s)Completed: 10/15/24 Well ID# 110 ft• 225 ft.
rock
5a.Well Location: ft. ft.
Chris Gray ft. ft.
Facility/Owner Name D#(if k'r 'C.,. Ta^
Facility i ( pplicable) ft. ft. U ,). ',t o t 't1- ��;
Ward circle dr Sparta, NC ft. ft.
OAT Q 2fl?4
Physical Addms,City,and Zip ft. ft. {+ I
Allegheny 21.REMA
RKS -,
County Parcel Identification No.(PIN) L:i(i.i3• .d
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.42262 N 80.04551
W •
C°r"zP-" 10/15/24
6.Is(are)the well(s)IJPermanent or OTemporary Signature of Certified Well Contractor Date
By siding this form.I hereby certifi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: L Yes or ONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and dat a
if this is a repair,fill out known well construction Information and explain the nature()like copy glans record has been provided to the well owner.
repair under#21 remarks section or on the hack 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
3.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: 225 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdgereiu(example-3@,200'and 2@I00')
construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Resources, •
If water level is above casing.use"+ Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: Sight 24c.For Water Supply&injection Wells: In addition to sending the form to
HTH the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 160Z completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 7.-27_7D16