GW1--06558_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: " .7 .
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES i '
Well Contractor Name FROM TO DESCRIPTION
4518-A 265 ft. ft. 20 gpm.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LiNER(if applicable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 25, it, 6 in. PVC
Company Name
373222 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
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
II Agricultural QMunicipallPublic ft. ft. in.
111 Geothermal(Heating/Cooling Supply) Id- Residential Water Supply(single) ft. ft. in.
jrji 1IndustriaUCommercial QRcsidcntial Water Supply(shared) 18.GROUT
C i Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft. 21 ft• Chips Poured
['Monitoring fC Recovery ft. ft.
Injection Well:
ft. ft.
®AAquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
111Aquifer Storage and Recovery I.0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
®i Aquifer Test f C Stormwater Drainage ft. ft.
111 Experimental Technology (C Subsidence Control ft. ft.
I iGeothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary')
, C Geothermal(Heating/Cooling Return) Other(explain under(/21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain size.etc.)
0 ft, 2 ft• sand
4.Date Well(s)Completed: 10/14/24 Well lD# 2 ft. 305 ft. rock
5a.Well Location: ft. ft. - t;.,. (•..'k--a '•i 4 t.,a )
e
Bob Ward-burns ft. ft. NO V t , ;n-'r
Facility/Owner Name Facility ID#(if applicable)
ft. ft. 'u - t-UL'1
Hamish dr West Jefferson, NC ft. ft. Ir ,;;;.;,.. l�-�••----a_ ,L
Physical Address,City,and Zip R. ft t✓•"+A.u'«rJ.y
Ashe 6 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 80.430 ter ,, G _ 10/14/24
6.Is(are)the wells)JPer manent or QC Temporar Signature of Certified Well Contractor Date
By signing this form,i hereby certi6•that the well(s)was(were)constnwied in accordance
7.Is this a repair to an existing well: QYes or ONo with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that e
If this is a repair,fill out known well construction information and explain the nature of the copy of rids 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
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
9.Total well depth below land surface: 305 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200•and 2@!00) construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
!fluster 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) 20 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-1 North Carolina Department of Environmental Quality-Division of Water Resources - Revised 2-22-2016