GW1--01403_Well Construction - GW1_20240301

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•WELL CONSTRUCTION RECORD(GW-1) . ..For Internal Use Only:
• 1.Well Contractor Information: - , - -
Cameron'Bazin •14.WATER ZONES ' •
Well Contractor Name FROM ' . TO "DESCRIPTION " - - . '
'400 ft': ft.• •2 9pm I .
4518-A . ft. . ft:.- . I 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. . 80 ft..•• 6 I ; in, " - PVC
Company Name -
01$670 • •16.INNER CASING OR TUBING(geothermal closed-loop) •
2.Well Construction Permit - FROM TO • - •DIAMETER THICKNESS •MATERIAL
' List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) 'ft.:- ft. id.
3.Well Use(check well use): ft. ,
Water Supply Well: . , 17.SCREEN . •
. FROM . . 'TO • - DIAMETER' SLOT SIZE '. THICKNESS . 'MATERIAL
ill Agricultural • !.0 Municipal/Public• ft. ft. in. .
Geothermal(Heating/Cooling' Supply) t•Residential Water Supply.(single) ft.... ft: in..
✓ii Industrial/Commercial a Residential Water Supply(shared) 18.GROUT
C Irrigation ". FROM TO ;MATERIAL '• EMPLACEMENT METHOD"&AMOUNT
.Non-Water Supply Well: .'0. ft.. 22 • ft! . .Chips', •.Poured , . , .
. E.Monitpritig:' • n Recovery . • . -ft.• . •• ft.. • "
. .Injection Well: . •
ft . ff.
10 Aquifer Recharge . )�Groundwater Remediation "1,9.SAND/GRAVEL PACK(if applicable)
11 Aquifer Storage and Recovery ,DC Salinity Barrier • .FROM • .TO , ' -MATERIAL- . . . EMPLACEMENT METHOD . .
I]'Aquifer.Test QStormwater Drainage •fr.. : ft..
E Experimental Technology QSubsidence Control ' ft• " ft. ,
. IN.Geothermal.(Closed Loop) .DTracel .. .. - : 20.DRILLING LOG(attach additional sheets if necessary)
•m Geothermal(Heating/Cooling Return)' Other(explain under#21 Remarks) FROM TO DEscR1PTION(color,nardaess sofuroek type;grain size,etc.).
: 0. •ft.: ' :70: • ft. •,sand
4.Date Well(s)Completed: - . Well ID# , 70. ft•,',' 625 .ft•• '.rock r i" :"' 1 ,r r'-:'->,,. • .
•
Sa.Well Location:• ft. ff. I ' 1--. �{
"Jerry Bryant'. ft.. . • .ft. . : • MAR la 1 2Q?d.
.Facility/Owner Name. , ' " Facility ID#(if applicable) . • ft , ft. ,
2670 US 21 Hamptonville, NC- • . ft.: . ft. ' mmorme4ten.ert-,cwa:re,tJla$,
.. .. . Lv`eil:-OC• ..
Physical Address,City,and Zip
Yadkin • 21.REMARKS .•
• i •
•County Parcel Identification No.(PIN)• • .
Sly.Latitnde'and longitude in degrees/minutes/seconds'or decimal degrees: . ' - ' • •
(if well field,one lat/long is sufficient)' 22.Certification:
36.10657- • .• 80.76584
N. . . . • W _. • 2/6/23
•
6.Is(are)the well(s)iJPermanent or.OTenrporary Signature ofCertified'Well Contractor, Date
By signing this form,I hereby cert fy.that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: . Yes •or.QNo with'15A NCAC 02C:0100 or 1SA 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: .
You.may use the back of this_page to• provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same.
construction,:only I GW-1 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: 625 • • (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: 1 ' '
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 276994617
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 ServiceCenter,Raleigh,NC 2769971636,
13a.Yield(gpm)•2. ..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 forth.within•30 days of
•
13b:Disinfection type: HTH Amount: 160Z' •completion of well construction!to''the county health department of the county
' where constructed. 1
Form GW=1 •North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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