GW1--06836_Well Construction - GW1_20241115

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
I.Well Contractor Information: '
.
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 450 ft. fit. t/2 ,
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
0 ft- 58 ft- 6 iu. PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 020742 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,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
ilil Agricultural OC Municipal/Public ft. ft. in.
II Geothermal(Heating/Cooling Supply) ORcsidential Water Supply(single) ft ft. in,
I .Industrial/Commercial IC Residential Water Supply(shared) 18.GROUT
C[Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 21 ft- Chips Poured
14 Monitoring ORccovcry ft. ft. '
Injection Well: ft. ft.
ElAquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
®iAquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
NI I Aquifer Test EtStormwater Drainage ft. R.
i!Experimental Technology ID Subsidence Control ft. ft.
lill Geothermal(Closed Loop) j C Tracer 20.DRILLING LOG(attach additional sheets if necessary)
C Geothermal(Heating/Cooling Return) In Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hanlness soil/rock type,grain size,etc.)
0 ft. 45 ft. sand
4.Date Well(s)Completed: 11/6/24 Well iD# 45 ft- 625 ft' rock
5a.Well Location: ft. ft. -
Jerry Bryant ft. ft. ,. a_y,, . ,;; ,i .
Facility/Owncr Name Facility iD#(if applicable) ft. ft. NUV J :; ;n2,4
4123 little mtn rd Jonesville, NC ft. ft.
Physical Address,City,and Zip ft. ft. ' •` -' 4i,;,'j
ti. .,
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:
36.19816 N 80.78968 W
6ter..2-/-% a - 11/6/24
OTemporary Signature of Certified Well Contractor Date
6.Is(are)the well(s)LPermanent or
By signing this firm.I hereby certii i'that the ueli(s)was(were)constructed in accordance
7.Is this a repair to an existing well: m Yes or ONo with 15.4 NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well conctr ciw,,in formation and explain the nature d f the copy aflhis record has been provided to the well owner.
repair under#2!remarks.section or an the hack of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
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: 625 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(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,
If tatter level is above casing,use"4-- 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
Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
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) 1/2 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-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016