GW1--01405_Well Construction - GW1_20240301

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IIIPrint Form
WELL CONSTRUCTION RECORD(GW-1) " "For Internal Use Only:
1.Well Contractor Information:
- I 1 • •
Cameron Bazin • 14.WATER ZONES
Well Contractor Name FROM • TO • " 'DESCRIPTION " .
' "265 ft-": ft 20gpm I I "
•4518=A - f •
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.. ,
0 , ft, 130 . tt,'.' 6, •
:in-, . . ' PVC
Company Name '
•1051 .16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List a!!applicable well construction permits(i.e.UIC County,State;Variance;etc.) ft.": : ft. i i-
3,Well Use(check well use): ft. , ft."' in.
Water Supply Well: 17.SCREEN
" " FROM' . . TO . . DIAMETER • SLOT SIZE THICKNESS . MATERIAL •
IN Agricultural •QMunicipal/Public " - ft. ft. in. .
11 Geothermal(Heating/Cooling Supply) Residential•Water Supply.(single) " fa: : ft. .in,,
1 IndustriaUCommercial , :DResidential Water Supply.(shared) 18,GROUT
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'Irrigation .- .: .. FROM TO - ' •MATERIAL ' . EMPLACEMENT METHOD&AMOUNT
"Non-Water Supply Well• ft;• ft. I
)d Monitoring, ••)Recovery •• fa' ft.
Injection Well: •
• tL
Ili Aquifer Recharge . El Groundwater Remediation• • •
19.SAND/GRAVEL PACK(if applicable)
.MI Aquifer Storage and Recovery .Salinity Barrier • .FROM. .TO . " •MATERIAL . EMPLACEMENT.METHOD •
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'I Aquifer Test '12'Stormwater•Drainage • fa " . ft.
in Experimental Technology ""•D Subsidence Control fc. it. . ." •
111 Geothermal.(Closed Loop) • '"QTracer 20.DRILLING LOG(attach additional sheets if necessary,
•I Geothermal(Heating/Cooling Return) C Other(explain under#21'Remarks) FROM • TO' DESCRIPTION(color,hardness,soiUrock type,grain-size,etc.)
>� g ( P
0 fL: : 120 ft sand
4.Date Well(s)Completed: 2/7/24 • Well ID#' ' 120 .ft-.', • '305 ft".• • rock' '
ft fL. ,
5a.Well Location: ' . .
Jerry Bryant ftfr. . . ..
Facility/Owner Name Facility ID#(if applicable) • `;i"L f �v 3. .
.Bagley springs rd Ronda, NC ft.: . " ft, U"
Physical Address,City,and Zip ft. f.• . ': PM. •• u X [{j24 . '
Wilkes 21.REMARKS tnii rm.—:.i f:1 1:_•
.. ". • .+ttr'°.:1 llfit
County Parcel Identification No.(PIN) DWQ/5'n=
' . 5b.Latitddeand longitude.in degrees%minutes/seconds or decimal degrees: . ' . ' " • ' -
.(ifwell'field,one!at/long is sufficient) 22.Certification:'
36.19936 • . N 80.8966.0 �, 1
� � 2/7/24
6.Is(are)the well(s)JPermanent or.[Temporary Signature of Certified Well Contractor' Date
. By signing this form,I hereby certtty that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EYes. .or"[:(1No. with 15A NCAC 02C:0100 or ISA 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 ofthis form. f
• .23.Site-diagram or additional well details'
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8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sable '•You.may'use the back"of this page to provide additional well site details or'well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details.•You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
depth below land surface: 305• • '
9.Total well - ft
( ) .24a. For All Wells: Submit this form within 30 da• ys of completion of well
For multiple wells list all depths Jd ferent(example'-'3@200'and 2©100') construction to the followings
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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 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 Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: sight 24c.For.Water Supply•&Iniecti in 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.:
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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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