GW1--01300_Well Construction - GW1_20240229

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WELL CONSTRUCTION RECORD (GW-1) I ;l?rintForm
For Internal Use Only:
1.Well Contractor Information:
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Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 245 fit. ft. 30 gpm
NC Well Contractor Certification Number ft. ft.
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Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) • .
FROM TO DIAMETER I THICKNESS MATERIAL
Company Name 0 ft* 1105 ft. I 61 in. PVC
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. I in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
12 Agricultural •Municipal/Public ft. ft. ; in.
1d Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
ft. ft. in.
IA 1 Industrial/Commercial Residential Water Supply(shared)
18.GROUT
['Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 fit. Chips Poured
11*Monitoring lRecovery ft. ft.
Injection Well: -
Ei Aquifer Rcchar c ft. ft.
g a Groundwater Rcmcdiation
li Aquifer Storage and RecoverySalinity Barrier 19.SAND/GRAVEL PACK of applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
1I Aquifer Test 0 Stormwater Drainage ft. ft.
IQ Experimental Technology JSubsidence Control ft. ft. '
I Geothermal(Closed Loop) [Tracer 20.DRILLING LOG(attach additional sheets if necessary)
C Geothermal(Heating/Cooling Return) 1C Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiuroci type grain size,etc.)
0 ft. 95 ft. sand
4.Date Well(s)Completed: 1/23/24 Well ID# 95 ft' 285 ft
rock
5a.Well Location: ft. ft.
James Atkins ft. ft.
Facility/Owner Name " °
Facility ID#(if applicable) ft. ft. + \CZ lP t+r /h.0
337 Woodlee Dr Advance, NC ft. ft. tS {!
Physical Address,City,and Zip ft. ft. t` 202'4
Davie 21.REMARKS isIibrinattg 7 P'^,r9 ti��I1isi^. "J h.
County Parcel Identification No.(PIN) D/�rrrYY�V,t7r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.02316 N 80.46457
W C ., ate_ 1/23/24
�IC Temporary Signature of Certified Well Contractor; Date
6.Is(are)the well(s)OPermanent or
By signing this form,t hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EYes or ONo with 1 sA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
Phis is a repair,fill out known well construction injbrntation and explain the nature ofthe copy(duels record has been provided to the well owner.
repair under#21 remarks section or on the back o#'thisform.
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: 285 (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 tt 100)
construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources
water level isshave casing,use +" ,Information Processing Unit,
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1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary 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:
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FOR WATER SUPPLY WELLS ONLY Division of Water Resources,fUnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13b.Disinfection type: HTH 160Z the addresses).above, also submit one copy of this form within 30 days of
Amount: completion of well construction to 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
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