GW1--00114_Well Construction - GW1_20231228

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ;I
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES {' r- -
WellContractorName FROM TO DESCRIPTION
85 ft. ft. 100 gem !
4518-A ft. ft. I
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. 40 ft. 6 1 in. PVC
Company Name
00122 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO. DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. j in.
3.Well Use(check well use): ft. ft. , in.
Water Supply Well: 17.SCREEN- •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
lig Agricultural QMunicipal/Public ft. ft. . in.
I Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single) ft. ft. in.
®Industrial/Commercial DC Residential Water Supply(shared) 18.GROUT
_C Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 24 ft. Chips. Poured
®Monitoring ©Recovery ft. ft. j
Injection Well: ft.. fa • -,
®Aquifer Recharge D Groundwater Remediation _
19.SAND/GRAVEL PACK(if applicable)
El I Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
lig Aquifer Test 0 Stormwater Drainage ft. ft.
®Experimental Technology D Subsidence Control ft. ft. 1
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ifi Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
II Geothermal(Heating/Cooling Return) LEI Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness solUrock 1p:.:r:,1s,ire etc.)
0 f- 10 ft' sand I•
4.Date Well(s)Completed: 12/21/23 Well ID# 10 ft. 125 ft. rock
5a.Well Location: ft. ft r,-^, .,._,
ft. ft. (�•f� .,:,.Tom Benton � - �.�;_, �.1:� ',^a
Facility/Owner Name Facility ID#(if applicable) ft. ft. !�F('-n O `. '
980 Dutch rd Mt Pleasant, NC ft.. ft. ~l• -1 O CO13
ft. ft. .CT,-..., `,•.... ;..-,.,,
Physical Address,City,and Zip
Cabarrus ' '21.REMARKS i .' "��`Ca. I " '"."t
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:
35.41113 N 80.39952 W
12/21/23
6.Is(are)the well(s)JPermanent or OTemporary Signature of Certified Well Contractor Date
• By signing this form,I hereby certity that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EjYes or QNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided tolthe well owner.
repair under#21 remarks 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also;attach additional pages if necessary.
drilled: I
SUBMITTAL INSTRUCTIONS!
9.Total well depth below land surface: 125 (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@100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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
Si
13a.Yield(gpm) 100 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. j
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016