GW1--01422_Well Construction - GW1_20240301

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¢ : Print Form
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WELL CONSTRUCTION RECORD(GW-1) -For Internal Use Only: ' •
1:Well Contractor Information: • . . I . .• -
ii .
. Cameron'Bazin . . • •14.WATER ZONES '
Well Contractor .FROM TO 'DESCRIPTION ' . . . . . . '
. '.385 .ft.•, : ft. 5-GPM I 1 '
.4518=A { .
ft • ft.• . . f I -
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NC Well Contractor Certification Number • -15.OUTER CASING(for multi-cased wells)OR LINER(if Op linable)
' Aqua Drill, Inc. . FROM '•TO. .-• DIAMETER.: •THICKNESS MATERIAL.:
• 0 ft: ' 100 - "ft' •• 6, • ! 'm. •''PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 02741- 'FROM . ' ' 'TO -. ' ' •DIAMETER THICKNESS' ' •MATERIAL . ' '
• - List 011 applicable wellconstruction permits'(i.e.•UIC County,State,Variance,etc.) • ft. ft 1, in •
3,Well Use(check well use):• tt to in '.
•
: 17.SCREEN
• Water Supply Well: : . FROM. . .TO .• . .DIAMETER' SLOT SIZE • THICKNESS MATERIAL -
©Agricultural. . •El Municipal/Public ft tt in. . .
II Geothermal(Heating/Cooling Supply) QResidential Water Supply(single)
0IndustrialJCommercial :QResidential Water Supply(shared).• -18.GROUT
I hrigation " .. . . .. . .. .• . .. FROM '. TO. ' MATERIAL '. EMPLACEMENT METHOD&AMOUNT
' .Non-Water Supply.Well .0 :ft.... 32-. ft. • .Chips;. Poured'. . . .
• - •,
Monitoring ••1M Recovery .. •ft' ' fL. - ' .
Injection Wells
Aquifer.Recharge' •10 Groundwater Remediation 1 - ' , .
_19.SAND/GRAVEL PACK(if applicable) .
. 1:11AqUifer Storage and Recovery •.El Salinity Barrier , . FROM ,TO _" - - -MATERIAL- _' _ EMPLACEMENT METHOD -
' EAquifer Test ' 0 Stormwater Drainage ft ft.
•.OExperimental Technology [jSubsidence Control.
.QGeothermal:(Closed Loop) . - I C Tracer. _ • • 20.DRILLING LOG(attach additional sheets if necessary), - . ... - .- '; .... ::. .
•FROM ' ' - TO - .DESCRIPTION(color.hardness;soil/rock type;grain size,etc.)
)�Geothermal(Heating/Cooling Return) • -1 Other(explain under#21 Remarks)
0 ft.: : .90: ft •sand!
4.Date Wells)Completed• ;•11/29/23 Well DM • ' • 90 ft. 425 ff- rock
•5a.Well Location: ft. fi. : •
't•.._i, i^ ,, p l^ _
. ' Hooker.Realty fL. - B. . : t V t L)
Facility/Owner Name " Facility ID#(if applicable) ' ' ft ftr • . - . ION
�.120? .
TBD Po lar Sp rin s:Rd Elkin,:NC : . `�
P P 9 ft: . ft. . . , mfo;�r.�.<.�n .-,,, ,,rr�_,.,.,
Physical Address;City,and Zip ft. • ft.... . I. • ' Dtitfo Or 2(' .
SUrry. 21.-REMARKS - -
County : ' Paicel Identification No.(PIN)
5b:Latitude and longitude.in degrees minutes/seconds'or decimal.degrees: • •• i
(ifwell'field,one lat/long is sufficient)' 22.Certification:. .
36.34059 N 80:80523 w, � ,.
• . Cam- ' ! 11129/23'
6.Is(are)the well(s)JPermanent -or.OTe'mporary. Signature of Certified Well Contractor Date
By signing this form,I hereby cert fy thai the well(s)was(were)constructed in accordance
7:Is this a-repair to an existing well:' I Yes or.ONO with.ISA NCAC 02C i0100 or.15A NCAC102C-.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. . - l
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-1 is needed.:Indicate:TOTAL NUMBER of wells: • • construction;details:•You may also attach additional pages if necessary.
drilled: - . . . • .SUBMITTAL INSTRUCTIONS -
'425. ' i
9.Total well depth below land surface: : - - (ft.) 24a: POI-All Wells; -Submit this form.within 30.days of completion of well
. For multiple wells list all depths.(fd�erent(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
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•11.Borehole-diameter:.6. . . • .(in.) 24b.For'Iniection Wells: hn.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,
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. : FOR WATER SUPPLY WELLS ONLY: 1636 Mail,Service Center,Raleigh,NC 27699-1636 "
' • 13a.Yield(gpm) 5 .Method of test: Sight . . 24c.For Water Supply•&Iniection Wells:-In addition•to sending the-form to.
the•address(es).above, also submitl 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourc Is Revised 2-22-2016•