GW1--00056_Well Construction - GW1_20231218

•
•
•
•
..WELL CONSTRUCTION RECORD(6W-1) : l • • I Pr Ir t Foam'
: - . - For Internal.Use Only '
1,Well Contractor,Information:.
•
. .. • .. Cameron BaZin ::. - • •• • :-WATER-ZONES -
. ' . Well ConamctotName. - ' ' • • -' - -
FROM TO DESCRIPTI -.
- ''4518=A . . .'. .
•NC Well Contractor Certification Number ' • '
15;OUTER'GASINC(for mull=cos�swells)'OR LINER-(lf ap 1lcable)
.Aqua Drill,Inc- •-FROM TO• •
•Company Name : . . .: . 0 . - ft'. '87 '. -ft. 6DIAMETER••, ' in, .THICKNE 7. SS -
• MATERIAL .
. 376844 16.INN ASING`OR TUBING(geothermal closed-loop)
PVC
2.Well Constpuchou Permit#i • • • ER'C
FROM TO. 'DIAMETER I n-- -THICKNESS MATERIAL; -
List all applicable wellwnstrnetion permits(i.e:UIC,CoittiV.'State,.Variance,etc) •tt. - ft. la
' • . 3.Well Use(check well use):. . , .: . ., r.4- • .
Water,Supply Well:. .
17,S
CREEK
- ' 1!1,gflClllhlf3l. . ' : -.- • - - - . . •DIAMETER•• SLOT SI7F • THICKNESS ' 'MATERIAL '10 MunicipaUpublic .. -. -
FROM -Tp .
' it: f) in
11 Geothermal'(Heating/Cooling Supply). jResidential Water Supply(single)
�C hldusttial/Commercial Residential Water Supply(shared) -
�Imgation . - -
- [t ft. • in.
•
•
NOR-WaterSuppiy.Well: ::
18:GROUT ,� - � � •
Monitor(ng. ..
'FROM TO "MATERIAL.-- ' EMPLACEMENT METHOD&•A.'VIOUNT
. _ QReco4ery '
.. . 0:. f 22
r. ,ft.:
Injection Welt. ft. ft:
Chips " Poured
1!Aquifer Rcchargc _ it: fL _ : . .
)L�Groundwatcr'Rcmcdiation -
13iAqutfer 8toiage:and,Reco"very �C Salinity Barrie• r
• • 19.SAND/GRAVEL PACK(if
. ' . FROM- . •TO •• -. MATERIAL .
Aquifer.Test. . 0 Stormwater Drainage.: : :ft.• ft!• EMPLACEMENT METHOD•-
. I Experimental Technology. • i'Subsidence Control' • -
ft . ft..
1I Geothermal(Closed.loop) ' .QC Tracer 20.DRILLING'LOG'(attacb additional sheets•If necessa
lC3 Geothermal(Heating/Cooling'Rettrm) Other(explain under ki Remarl(s) •
FROM To. DESCRIPTION(color,hardness solUrask type'arain size etc.)
. .' .. . . . • .p. t 80 . ft . sand.'.:
-4-.Date Wells Com-leted: 12/11/23 ' • •- .
O p � Wel11D# - 80' : •ft.: 705. 'ft. rock' .•
5a-Well Location: • k'~
• • Phil Kelley : • ft. • f. • 4 ;•,• '. .�
Facility'/Owner Name. DL L
. . Facility 1D#(if applicable)- -:- It • ' ft ' '.. . • —L.7 •1. b • -
Whi• pporvuill rd.Mocksville NC • • • • 1��3
. Physical Address,City,and Zip .: •• • • ; R- : •' '• ft, •. .. ••.' 14;t ? a
Davie' .. Parcel Identification No.(PIN)'
Sb.Latitude arid longitude•in degrees/minutes/seconds or decimal degrees: - • -
(if well field;one lat/long is Sufficient) • - ' .. • : '. :' 22:Certification: •• • -•
36:04199 iv 80.53818 " -
Cam;. ,( • 3 .
W 12/11/23 Is(are)the well(s)13Permanent : or jC Temporary Signature of Certified:Well Contractor
Date.
.: . •Bp signing'tliis form,I hereby certify that the well(s)was(were)constructed In accordance
7.is this a repair to an existing wells, NA Yes, or No 7 trill:15A NCAC:02C:0100 or 15A NCAC 02C'.0200 Well Construction Standards and that a.
If this is a repair,fill out known well construd/an:infor i,ation and erplaln tho nature o/the copy.elks record has been provlded.to t/re well owner. • - 'repair under#21-re,uarls section or on the back(of this form.' •
23.•Site diagram'or dditioaai wall details •
8.For Geopi'obe/DPT or.Closed-Loop Geothermal.Wells having the same You itiay use the back of this page to provide additional well site details or well construction;only 1 OW-1 is.needed. Indicate TOTALNUMBER of.wells- • con may also'attach additional pages if necessary.
drilled ' �. :. •
struotion details. You
- SUBMITTAL INSTRUCTIONS.
9,Total Well depth below land surface::_705 • (ft) •
For.multiple wefts list al/depths j%different(example-3e?00'and 2(d i00') - 24a,')~or-All Wells: Submit this fornt within 3t) days of:completion.of well
constriction to the following: •
10:Static water level below top of casing:•. .
brunter level is above easing,use + (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter;-6 - (in.) .
1617 Mail Service Center,Raleigh,NC 27699=1617
24b,For Iniection•Welts: In addition to sending the form to•the address in 24a
above;also submit one copy of this form'within'30 days of completion•of well
12.Well construction Method: 'Rot8fy
(i.e.auger,rotary,cable-,direct:push,etc.)
constriction to the following;-
• FOR WATER SUPPLY WELLS ONLY: - • •• '
Division of Water Resources,Underground bleak*Control Program,
1636 Mail Service Center,Raleigh,NC 27699,1636' .
13a,Yield(gpm) U. .: Method of test: 24c;For Water.Supply&Infection Wells: In addition to sending,the form to
the addresses) above; also submit'lone copy of this form within 30 days Of
13b.Disinfection type: • . Amount: - • •completion of well construction io 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 •