GW1--01055_Well Construction - GW1_20240212

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Print Form
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WELL CONSTRUCTION RECORD(GW-1) .For Internal Use Only:'
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1:Well Contractor Information: ; .
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• -Cameron Bazin • , , 14.WATER ZONES .
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Well Contractor Name .FROM . TO . DESCRIPTION . . . ,
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245 ft'. : ft.. 30 gpm I 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 . • MATERIAL.. .
• ft • 105 ft. 6 in • PVC
Company Name '
399635 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 in.
3.Well Use(check well use): . ft. ft. . in.. .
Water Supply Well: ,. 17.SCREEN •
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FROM- . . TO _ DIAMETER' SLOT SIZE THICKNESS . MATERIAL •
-.1:3 Agricultural -I Municipal/Public• ft. - ' ft: ' ••in. .
©Geothermal(Heating/CoolingSupply) QResidential Water Supply(single) ft.-. : ft: • -in. ,
:©Industrial/Commercial •I Residential Water Supply(shared) 18.GROUT '
©C Irrigation - .. . . FROM TO ' .MATERIAL' '._ EMPLACEMENT METHOD&AMOUNT_
.Non-Water Supply Well• . . '0 ft 20 'ft .• Chips `Poured .
,�'C)Monitoring . I Recovery . ft.•• ft. . ;
Injection Well: • -
Q[Aquifer Recharge 1 Groundwater Remediation fa ft,
19.SAND/GRAVEL PACK(if applicable) '
.DAquifer Storage and Recovery - _ii Salinity Barrier. , . . . FROM. . .TO .' MATERIAL- . . EMPLACEMENT.METHOD .
' Aquifer Test EIStormwatei Drainage ft• ft.. - I
'.0ExperimentalTechnology -.D Subsidence Control ' ft.. . ft. . . ' {
.O.Geothermal(Closed Loop) .Tracer . , . • • • 20.DRILLING LOG(attach additional sheets if necessary) -
1g Geothermal(Heating/Cooling Return) ' Other(explain under#2I Remarks) 'FROM TO - • .DESCRIPTION(color,hardness,soiUroek type,grain sin,etc.).: 0: . it: : 95 ft sand .
4.Date Well(s)Completed:•1/23/24 Well ID# 95 ft 285 ft''' .rock
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5a.Well Location: fr.' ft. r� .-t .3"
James Atkins ft. ' ft. . - �- L 1 kor c U.
• ft . ft' • . I- i 22nZn
Facility/Owner Name Facility ID#(if applicable) �'�
.337 Woodlee Dr-Advance,-NC ft.: ft.
Physical Address,City,and Zip ft' ft.. "d"'�alc'ri i.ii r ,.
13r a.-,3
Davie . . 21.REMARKS .
County Parcel Identification No.(PIN) ,
56;Latitude and longitude in degrees%minutes/seconds'or decimal degrees: . . I . •- -
-(ifwell field,One lat/long is sufficient)' 22.Certification: I
36.02316 N 80.46457 N,
C-Wl- • 1/23/24
6.Is are the wells d Permanent or. C Tem ora Signature of Certified Well Contractor 1 Date
By signing this form,I-hereby cert .that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: . EYes or ZNo 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,only 1 GW-I is needed:Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: -SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface:• 285 fl
P ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifderent(example-'3@200'and 2@100) ' construction to the following: r
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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
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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.e.auger,rotary,cable,direct push,etc.).
Division of Water Resources,Underground Injection Control Program,
: FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service i Center,Raleigh,NC 27699-1636.
13a.Yield(gpm)'30 _ Method of test: sight 24c.For Water Siinnlv&Infection 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..
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Form GW-1 • North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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