GW1--07912_Well Construction - GW1_20231208

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'Point Form ,
WELL.CONSTRUCTION RECORD(GW4) For Internal USe Only:
: I.Well Contractor Inform ation:
Cameron.Kazin:
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14:WATER''ZONES . .....-
Well ContraetorName '
. .. . . FROM. -TO DESCRIPTION -. .- - - . •
4518-A 205 ft. ft.. 5 GPM
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.NC Welt ContrOb:Ccnification Number
15:;OUTER CASING-(for multi-cased_wells)OR LINER(Ifap'llcable)
. : . Aqua Drill, Inc. • FROM • TO • DIAMETER - ' THICKNESS • : MATERIAL
Company Name .. . p R,'. 96: . ft:. 6 In.. : ... . • PVC
2.Well•Construction•Permit#:•02878.• . . - . INNERFFRROCASING R'TUDIAMETER •' THICKNESS. MATERIAL
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List all ap"p/ieable well construction permits(f.e.'U/C,.County:'Slale,Variance,eic) ft R: in,• '
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•-. .3,:Well Use(check welLuse): fE ft: In:
Water Well: - 17.:SCREEN :.
FROM-• TO. . - DIAMETER; St.o'r SIZE" `THICKNESS .!MATERIAL '.'. Ii0 Agricultural M Municipal/Piiblic -
ft rt: In.
' !Geothermal(Heating/CoolingSupply) Residential Water Supply(single) :. : '
. ft.' ft. "in. _
Alilndustrial/Com mercial • (jC Residential Water Supply(shared)
CImI ation. . . OUT• FROM. TO MATERIAL .EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: - - :. • 0 ft • 125 - ft*, . Chips:. . ' Poured' :.. . '
I1'Mondorin& QRecovery ft. R
Injection Well.
1 I Aquifer Recharge . 1/Groundwater Remcdiation• .. •
ft: rt;
j�iAquifer Storage and RecoverySalinity Barrier - • AND/GRAVEL PACK(if applicable), _-_- -
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•195 "
FROM TO MATERIAL _ EMPLACEMENT METHOD
. li iAquiferTest E[ StormwaterDrainage ft; R:' :' . .. .
• . • 1 Experimental Technology JSubsidence Control ft: • • :.R;- • • • • :.
�,Geotheinial(Closed'L"oop) Tracer '
•' 20.•DRILLING LOG(attach addltlonal'sheets if aeeessaty)
[Geothermal(Heating/Cooling Return) • C Other(explain under#21 Remarks) FROM To. D>est RIPTIon(rntor,hardness solumek Sept,grain sire eta)
• 17J1/23
90: sand,
4.Date'Well(s)Completed: Well ID# gp It.. 5 'ft. ro
24 Gk" ..
Sa.WellLocationt it •: ft. - :
. Dalton'Reynolds e: ,ft. , . • .
Facility/Otvtter Name pP - •
ft f • r..+Facility ID#Ofa applicable) t. 'CsL
1721. Ladle Ford Rd Mt Airy, NC_ . u • rL ,t;;;.,
Physical Address Cily,and Zip ft ft. U t,�,rr�7 • a:
•Sur • . .
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• County• : Parcel Identification N9.(PIN)• • •
-Sb:Latitude and longitude.in degrees/minutes/seconds or,decimal degrees: -- •
(if well field;one lit/long is sufficient) "' 22:Certification
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36.46618 • N 80:69296 .. . •
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!i lt�.: -
12/1/23
- 6.Is(are)the well(s)IOPerrnanent or DiTcMporari Signature of Certified Well Contractor - Date
• By signing this jinn,1 hereby•certify that the neii(s)Was(urge)constructed in accordance
7.Is this a repair to an existing Dyes or ONo With ISA.NCAC 02C.0100 or ISA NCAC 02C.0200 Ifreli Consl,uction Standards and dial a. -phis is a t epalr,fill out/room,ice/I construction In/imitation arid explain the nature of the copy ofthis record'has been provided to the moil miner: ' '
repair under 112/,remarks section or on the batik 0I'thisform: • '
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 I 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: 245 • -IN 24a. For All Wells:' Submit this form within 30 da
For niu/lip/e nails list all de/iths Ifd event(e-rantple-.3[7a 200•and 2@l00)' " y5 of coiltpietion of well
constriction to the following:-
10.Static water level below top of casing: 40 (ft
If Water level is above.casing,use"+•• ) Division of Water Resources,Information Processing Unit,
1617 Mall Service Center,Raleigh;NC 27699:-1617
I1.Borehole diameter: .6 • (in.) 24b.For Infection"Wells: In:addition to sending the form to the address in 24a
11 Well construetion method:..Rotary above,also submit one copy of"this form within"30 days of completion of well
(i: push,
e.auger,rotary,cable,direct 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) 5 Method of test; Sight 24c.For Water-Supply&Iniectil n Wells: In addition to sending the form to
13b.Disinfection e; FiTH 160Z the addresses) above,, also submit one copy of this form within.30 days of
typ Amount: • completion of well construction td,die county health department'of the comity
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2 22-2016,