GW1--07914_Well Construction - GW1_20231208

I�Prin
.RECORD(GW-1) For Internal'Use Only:- I -
Form'
WELL CONSTRUCTION •
I..Wel1.Contraetor Information:
•
-Cameron Bazin
19i;WATER'ZONES.
Well Contractor Na me .-' FROM. ' TO DESCRIPTION• :•-
4518-A 125 ft. It* 25 GPM.
IL' . .ff
- NC Well Contractor Certification Number r
15:OUTER;CASING(for mutti<osed•wells)OR LINER(Iiap Noble),Aqua Drill, Inc. •FROM TO • • .DIAMETER . THICKNESS.]•, .MATERIAL •' '
Company Name -. • .. , ft:
.". : 0 . 8 •' ft. .ti PVC
3 In. .
• • •01818 16a INNER'CASING OR:TUBING(geothermal closed-loop) -
2.Well Construction Permit#: _ •• - . • . _ • FROM TO - DIAMETER THICKNESS- -MATERIAL i.'
List all applicable Wellconstruction/iernits.(I e.UIC,.County,State(Variance,etc-)
• 1:Well Use•(check well use): ft.. - ft. tn:
Water Supply Well: . . ..• • .. • • . 17-SCREEN`.
.PROM, TO DIAMETER: SLOT SIZE-- THICKNESS' MATERIAL Agricultural . • • CMunicipal/Publc ft. it, In.
•
Geothermal(Heating/Cooling Supply) Residential Water Supply.(single)
ft. ft. ,in.
•
El Industtia1fCommercial ' IJC Residential Water Supply(shared)
C litigation. oUT
. .
•18•GR
•
•
FROM • TO . MATERIAL • ...EMPLACEMENT METHOD&AMOUNT
.. Non Water Supply Well ' . . 0 - it g... C
la Monitoring -• .: . l�Recove . . - P.... : r
ry : rr: ft.
_ 25
Injection<Well: hi s.. Pou ed
i Aquifer Recharge. - : kg Groundwater Reincdiation ' . • • •
ft ft.
Storage and Recovery Salini BarrieY • 19:`SAND/GRAVELPACK•(if applicable) • ,
AquiferMi
. .. .0 Mint, - FROM • "TO.• • -. 'MATERIAL •' . .-_EMPLACEMENT METHOD• .
J Aquifer Test. O$torlttwaterDrainage
Ill Experimental Technology. •DSubsidence Control ft;: tL: !• • • •_ -: -
l0!Geothermal(Closed Loop) ' C Tracer - . . . • •' e .' .- _
20:DRILLINGZOG(attach addltlotial sheets It necessary) - _
li!Geothermal(Heating/Cooling Return) lJOther(explain under#.21 Remarks) FROM. TO DESCRIPTION(rotor,hardness sowroek
11/28/28 • • 0. ft! 75- .
type,grataslze.eta) .
n•' sand'
4.Date Well(s)Completed: : Well ID#• ' .. 75 R• 185 .R•. rock .
5a.Well Location:
Alan Welch • �(
•
Facility/Owner Name Facility ID#(if applicable). ft' ft:• -.7"-"1256.Poplar Springs Rd Elkin, NC ft• n. • �L 8 ZCt[3
Physical Address,City,and Zip" '
Sorry. .. 31.REMARKS. �- `County . . .. . , Parcel Identification No.(PIN),.
Sb:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
given field;one lat/long is sufficient) 22.Certification:
36.34018 N 80.80538
i�• .11/28/23
6.Is(are)the well(s)0Perrnanent or C Tem ora Signature of Certified Well'Contractor "
�... P . ?Y . Date
ay signing this faint,I herebv'certlfy Altai the hell(,)was(,rote)constricted in accordance
7.is this a repair to an existing-well:. 0Yes. or'ENo filth/5A NCAC.02C:0100 or!SA NCAC'02C.0200 Well Caaslnrctlon Standards and Matd f uns is a repair fll out kno)i,well canstnrciion ii fortnallon and explain the nature of the copy of this record has been provided to the Well onner
repair order-#2/remarks section or on the back'ol'this fora: .
,23.Site diagram dot additional well details:
8.For Geoprobe/ PPT 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-I is needed. 'Indicate TOTAL NUMBER of-wells constriction details,You may also attach additional pages if necessary.
• drilled:' . ..
SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface:. 1 85 (ft.) 24a. For All Wells: Submit this form within 30 days
For multiple wells list all depths fd�erenl(eraniple-3ca 200'and 2@i00') of coitipletioII of well
oonstnietion to the following:
10:Static water level below top of easing: 40 ft-
IIftinter level is ahove,casing:rose"+^ ( ) Division of Water Resourcesylnformation Processing Unit,
1617 Man Service Center,Raleigh;NC 27699-1617
• II:Borehole diameter:'6 (in.) 24b.For Iniection'Wells: In addition to sending the form to the address in 24a
12.Well co struetion method: Rotary above,•also'submit one copy of this form within 30 days of completion of well
(i.e.auger,rota sh
rotary,cable,direct peat,etc.) construction to,the following:
•
FOR WATER SUPPLY WELLS ONLY:FOR of Water Resources„Underground Injection Control Program,
1636'Mail Service Center;Raleigh,NC 27699=1636
Ma:Yield m 25 SI ht 1 ,
(gp ) . . Method of test: . 9 •24e.For Water.Suavity&Inlection Wells: In addition,to:sending the form to
HTH the addresses) above, also stibntit one'copy of this form within.30 days of
13b.Disinfection type; Am 160Z ount; _ completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department ofEnvironntcntal Quality-Division of Water Resources
Revised 2-22-2016