GW1--06557_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ,.
1.Well Contractor Information: I
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A - 450 ft• ft. 112 gpm -
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 195 ft. I 6
in. I PVC
373223 16.INNER CASING OR TUBING(geothermal closed-loop)
Z.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable rreli construction permits(i.e.UlC County.State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
III Agricultural QMunicipal/Public ft. ft. in.
ID Geothermal(Heating/Cooling Supply) Ellitesidential Water Supply(single)
it. ft. in.
®'Industrial/Commercial C Residential Water Supply(shared)
18.GROUT
['Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 24 ft. Chips Poured
EliMonitoring QRecovery ft ft.
injection Well:
Aquifer Recharge ft. ft.
a QGroundwater Remediation
®I Aquifer Storage and Recoveryn, 19.SAND/GRAVEL PACK(If applicable)
C Salini Barrier FROM TO MATERIAL EMPLACEMENT METHOD
it!'Aquifer Test El Stormwater Drainage ft. ft.
E Experimental Technology 0 Subsidence Control ft. ft.
111 Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
f Geothermal(Heating/Cooling Return) !C Other(explain under#21 Remarks) FROM To DESCRIPTION(rotor,hardness,soil/rock type,grain size,etc.)
0 ft. 85 ft• sand
4.Date Well(s)Completed: 10/15/24 Well iD# 85 ft. 705 ft
rack 1'- :17:.'-'
:� ;;'• ,•-- -',
e... l a a .,..
5a.Well Location: ft. ft.
Mitchell Stewart ft. ft. NU V a 1 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Hamish dr West Jefferson, NC ft. w-
L% s-i 4' i�
Physical Address,City,and Zip ft. ft.
ashe 7 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:
36.35123 N 80.43023
Wes' 10/15/24
6.Is(are)the well(s)JPermanent or QC Temporary Signature of Certified Well Contractor Datc
Br signing this form.I hereby cer4fr that the null(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or QNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this Ls a repair,fill out known well consbuatinn information and explain the nature alike copy of this record Jars been provided to the well owner.
repair under till remarks section or on the hack of this fom u.
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-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: 705 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a 200'and 2(a3100)
construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Resources,Information Processing Unit,
firmer level is above casing.use'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection 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
(Le.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) 1/2 Method of test: sight 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfectiontype: HTH 160Z the address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well construction to i the county health department of the county
where constructed.
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016