GW1--00776_Well Construction - GW1_20240131

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: '
Cameron Bazin 14.WATERZONES
Well Contractor Name FROM TO , DESCRIPTION
165 ft. ft. 15 Gpm I '
4518-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM _ TO DIAMETER THICKNESS j MATERIAL.
0 ft. 128 ft. 6 i in. PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 02546 FROM . TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: -
FROMN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QC Agricultural QC Municipal/Public ft. ft. in.
IP Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) g• ft. - in.
0Industrial/Commercial DC Residential Water Supply(shared) 18.GROUT
Eri Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 28 ft• Chips' Poured
oC Monitoring I3 Recovery ft. ft.
Injection Well:
ft. ft.
Ql: Aquifer Recharge I3 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑IC Aquifer Storage and Recovery Ilj Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
CC Aquifer Test 19 Stormwater Drainage ft. ft.
•
•
Experimental Technology li Subsidence Control ft. ft.
QC Geothermal(Closed Loop) °C Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
EC Geothermal(Heating/Cooling Return) ❑C Other(explain under#21 Remarks)
0 ft• 120 ft• Sand
4.Date Well(s)Completed: 1/16/24 Well ID# 120 ft• 185 ft Rock'
ft. ft.
5a.Well Location: i` T
Steve Bottoms ft. ft. ' '='t 4'n,j0 L.-i! ;.,r F
Facility/Owner Name Facility ID#(if applicable) ft. ft. J/1 A, 2O2
195 Creek Ln Ararat, NC R• ft. ni T
ft. ft. sl K:.•L:"�
Physical Address,City,and Zip >.c.Cs.. ,.'-
Surry 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one 1at/long is sufficient) 22.Certification:
36.410 N 80.59710 W
1/16/24
6.Is(are)the well(s)IDPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JO Yes or ONo 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 to the 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii 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
I '
11.Borehole diameter: 6 (in.) 24b.For Iniection 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
(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
13a.Yield(gpm) 15 Method of test: sight 24c.For Water Supply&Iniecition 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 Ito: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