GW1--00004_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECORD GW-1 t
Only: ..
Pint rl)flll,
For Internal Use ,
1.Well Contractor Information:
Cameron;6aziri • • • . _ - '- •-- • '
' • . Well Contractor Name • ., : FR MWATER ZONES : -: DESCRIPTIOR
. . 451.8-A ' .. • sss: •ft : • . • rt .30 GPM! • - . ..
ft:
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NC Well Conttactor.Ccrtifieatiop Number:.•
• ISi.OUTER-CASING_(for multi-cased,wells)OR LINEW pfin licable)
Aqua Drill, Inc:
Company Name 0•
FROM :99. L IDIAMETER. :. in, • • ,
t
•• 0894'. INNERCASING OR TUBING!(geothermal closed loo -_
MATERIAL• '
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16. pl PVC
2,*ell Con •
struction Permit#. •- ' .'FROM ' TO
DIA
' ' •' List all applicable well constniclion perrnUs r(LeUIC(aunty°State„Variance,etc.) • •fL • ft:• .•• ; :.:: Ia,
dt� THICKNESS.••- `MATERIAL
. 3.Well Use(check well use)e : _ . :ft. , fL' 'in:
Water Supply Well:- . • : .. . ..
e • • 17:'SCREEN___
" FROM " TO `DIAMETER' SLOT SIZE •'"THICKNESS - "MATERIAL'--
IS Agricultural : • - I Municipal/Public
, ' ft .ft. In.' •
RS Geothermal(Heating/Cooling Supply). Residential Water Supply(single) .. - ' -
' 'fL ' :fL in.•
11 Industnal/Cotiimercial :': . . El Residential.Water Supply.(shared) •
C i Irrigation . • � .. . OUT ..
18.;GR .: ... . ••. ,..
FROM TO_ MATERIAL. .. EMPLACEMENT METHOD'&AMOUNT '
Non-Water Supply Well, • • •• • .ft.; ft:• Chi s
silMoriitoriiig . :. . . :. E3Recovery , .. , .. . • ,
0 .24'
t.
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Injection Well
Poured' '
• 1131AquifcrRecharge_ : - l�GroundwaterRemcdiation :. • •
�iAquifer Storage and Recove ry . Salinity Barrier: To applicable)
19,SAND/GRAV,EL PACK(if . "
� FROM ..--MATERIAL TERIAL • EMPLACEMENT METHOD
I lAquiferTest . :• .oC StotritwaterDrainage.. 'ft.' .ft• : : -. •.::'., . . .-...-' , .. . .:.... :'....--.... •'•...: : '..*. ' ;... - ..
• . - " ' .II Experimental Technology••: Subsidence Control .: '::k • -it:.-':.
. Geotheitnal(Closed'Loop) Tracer - -'. .': • ••' ' ' 20:.DRILLING'LOG(attach additional sheets If necessary)' •
• FROM -TO - .DESCRIPf1011(trotor,dardness,aolUrackRpe,grdlnsbe,efal -
Il�Geothermal'(Heat mg/Cooling Return) '�C Other.(explain under#2I Remarks)
p :.tt 90 ft sand,
.4.Date Well(s)Completed:.12/ Well 1D# 80. fe '' 5 ft. •• • rock : •
5/28
',So.Well Location: • -. . • • ft,. • , " . i'•r}*� T. ,.fr - ' ) .
. Dap',Cooper . . .:ft. .
.1 J ;i.
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. • Facility/owner Namc • ity ID#(if applicable]. •Facil ft.' '•. ft°• -�- W
3250 Gladys Fork rd Ferguson, NC
-. _• a.. :• .:ft. - • • . ,;.-.;.•,:•r..::•':;;::��---
Physical Address:City,and lap. .. ft. °��
' • : Wilkes
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21.REMAR[ES
' Parcel Identification No.]PIN),; _
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees: • '
(if well field,;one lit/long iS sufficient): •• '
36.09122. •. . N 81.40853 • ' '
22.Cerdtication:
6.Is(are)the well(s)1aPernianent .or_'QC Temporary. ' Signature of Certified Well Contractor Date..
Z:Is this a repairto an existingwell: - '0.signing this forth I"herein cetijy that the'ttiell(.c)was(aeire):eanctiucted inaccordance
Ill Yes Or DNo :with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Tell Construction Standards and.ihat a , -
Ifthis is a'repair fill out larpnn well construction information and explain the nature gf the " copy:of t/or record has been provided to tlie.tiell'miner,.• ' ' .. ' '
repair under#21 remarkf section or on the back 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-i•is needed.•Indicate TOTAL NUMBER of wells • may also attach additional-pages if necessary.dulled: ':. ... . . • ... . . . .
construction details:.You
• SUBMITTAL INSTRUCTIONS
9,Total Weil depth below land surface: .8•• (ft:)
For multiple n el/s list all depthrs ifd*erent(example=3@200'and 20100) 24a. For-All'Wells: Submit this'�forin within 30.days'of.completion of well
. • 'construction to'the following: •
10.'Static water level below top of casing:40 . . . '. ft:
(.) •Division of Water Resources,Information Processing Uoit, •
If water level is nbot a casing,fuse 't" ,
• - 1617 Mail Service Center,Raleigh;NC 27699-11617
' IL Borehole diameter: 6 .. •• '(in.) .
• 241i.For Infection Wells: In addition;to sending the•form to the address in 24a
12,Well construction meth'odk. RotarS. . , 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:
FOR WATER SUPPLY WELLS ONLY: : Division of Water Resources,Underground"Injection.Control Program,.
163.6.Mail Service Center,Raleigh NC 27699-1636: • • •
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13a..Yield m '30 $i ht
(gP ) Method of test • g 24e.For Water Supply&Infection Wells: In addition to sending the form to. .
13b.DisinfecHori e; HTH 160Z the addresses)above,'also•submitlIone copy of'tliis form within 30-days of
. . ty'p Amount: - ,completion of well construction to the. county health"depaitment•of the county
• . • . where:constructed. - • I I
Form GW-I North Carolina Department of Environmental.Quality.-Division of Water Resources
Revised 2-22-2016