GW1--01423_Well Construction - GW1_20240301

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WELL CONSTRUCTION RECORD(GW-1) • .For Internal Use Only:
1..WeII Contractor Information: • - -
Cameron Bazin 14.WATERZONES .
.FROM TO •DESCRIPTION
Well CotlractorNaine
.-185 ft•'. : ft• 15 9pm I -
4518-A
ft ft:: . "
NC Well Contractor Certification Number
•15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
. Aqua Drill,.Inc• .. • FROM TO. DIAMETER:: THICKNESS . MATERIAL ` . —
.0-- _ fi' . Ion- •ft.'-... 6 • I in, • . - -'PVC ..
Company Name
3618 .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 m- .
3•Well Use(check well use): is ft
.. ••Water Supply Well: 17.SCREEN '
. FROM . TO DIAMETER'. SLOT SIZE THICKNESS . MATERIAL '
'Agricultural . . '- C Municipal/Public ft. f4 in. .
©Geothermal(Heating/Cooling-Supply) " 'Residential-Water Simply.(single) - : ft... . . ' ft, : in.
QC Industria1/Commercial • . :[Residential Water Supply(shared) 18,GROUT •
C'"Irrigation- . .. _ .. .. • .. . . FROM . TO" - •MATERIAL . EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: •0 'ft .30 ft• . .Chips. Poured
Monitoring• . 11 Recovery , fit ' fr. '
Injection Well:
ft. ' ft. • .
'Aquifer Recharge 12 Groundwater Remediation. - .
19.SAND/GRAVEL PACK(if applicable)
.'Aquifer Storage.and Recovery - , •NI Salinity Barrier " .FROM - . TO • -MATERIAL , , EMPLACEMENT,METHOD
' QAquifer,Test ' . QStormwater Drainage ft. ft..
'".'Experimental Technology " DSubsidence Control tt. ft• . .
•
C Geothermal(Closed Loop) - .'.Tracer • 20.DRILLING LOG(attach additional sheets if necessary)" -
• C Geothermal(Heating/,Cooling Return) "f Other(explain under#21 Remarks). "FROM TO DESCRIPTION(colon hardness,soiUrocktype,grain sae,etc.)
0 ft.: : .90. ft,
.sand j
• 4•Date Well(s)Completed: 2/1 9/24 Well ID# ' 90 ft', • 225 tt•'. '. rock
Sa.Well Location:- ft..
t : ft.
. ft.. - ft. . . i. I 1 f
Jim Scott �L�' s�
Facility/Owner Name . ' . Facility IDS(if applicable) ft. fit. - "'�
1038 Spainhour mill:rd Pinnacle;NC" - •ft.:� ft. MqK A �UL4
ihvr •
Physical Address,City,and Zip ft. " . ft." • iti,3gjF�1 iDr,.- T�e
Stokes 21.REMARKS "ry Q/itp "a rr;• •
County. Parcel Identification No.(PIN)
5b:Latitude and longitude in degrees/minutes/seconds or decimal degrees: '" . " -
.(ifwell-field,one lat/long is sufficient) 22.Certification:
• 36.28040 N 80:45068" .: W '
" ! " . • . . -2/19/24
6.'Is(are)the well(s)iPermanent -or.[Temporary Signature of Certified Well Contractor Date
•
. By signing this form,1 hereby cert9,,ihat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or.ONO. with.ISA NCAC 02C.0100 or I5A 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. ' • • I•
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
9.Total well depth below land surface: 225 " (ft.
P ) 24a. For All Wells: •Submit this,form within 30 days of completion of well
For multiple wells list al!depths.ifd�erent(example-..3@a 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,ttse"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole"diameter:• 6 - m.
—( ) •
24b.For infection 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: I
con§traction to the following:
. (i.e.auger,rotary,cable;direct push;etc.) 1 , -
Division of Water Resources,Underground Injection.Control Program,
: FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 " Method of test: sight -, 24c.For Water Slimly&Iniection 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016