GW1--01555_Well Construction - GW1_20240308

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Cameron Bazin 14.WATER ZONES • - ' . • •
Well Contractor Name .FROM TO 'DESCRIPTION . .
'285 fc ft. 6o gpm
4518-A I
ft ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if sip licable)
Aqua Drill, Inc. FROM TO.. DIAMETER.. THICKNESS • MATERIAL..
0 ft' 45 . ft' • 6 • 1 'in. 'PVC
Company Name
3901 16.INNER CASING OR TUBING(geothermal closed-loop)
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2.Well Construction Permit#: ' 'FROM- . TO • "DIAMETER . -THICKNESS -MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft." " ft. . in.
3.Well Use(check well use): fa . • ft.. in.
Water Supply Well: 17.SCREEN .. -
', FROM . . TO . . . DIAMETER SLOT SIZE THICKNESS . 'MATERIAL
I Agricultural Municipal/Public ft. ft: ' in:
Ig Geothermal(Heating/Cooling Supply) d Residential-Water Supply.(single) ft. : ft: , in. "
1 Industrial/Commercial ; G Residential Water Supply(shared) 18.GROUT - '
_E Irrigation FROM TO • " :MATERIAL . EMPLACEMENT METHOD&AMOUNT
. .Non-Water Supply Well: 0 ft• •22 ft• -Chips; ,Poured,". . '. • ,
J Monitoring: . I. Recovery ft ft.- - '
,Injection Well: • .
&. '_ ft,
)D Aquifer Recharge ©Groundwater Remediation • . . . .
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19.SAND/GRAVEL PACK(if applicable)
le Aquifer Storage and Recovery "Salinity Barrier . FROM. . .TO . ' -MATERIAL EMPLACEMENT.METHOD . .
l Aquifer Test QStormwater Drainage fa• • fi..
II Experimental Technology "Subsidence Control ft. .ft.
. 11 Geothermal(Closed Loop) . Tracer 20.DRILLING LOG(attach additional sheets if necessary) -
' FROM ' . ' TO • .DESCRIPTION(color,hardness;soil/rock type,grain size.etc.)
lig Geothermal(Heating/Cooling Return) 'COther(explain under#21 Remarks) • 0 fL" 40 fr sand
4.Date Well(s)Completed: 2/16/24 Well ID# 40 ft• , 325 ft• • rock _
5a.Well Location: ft ft. aJ '! i
CMH homes ft ft ii
Facility/Owner Name ' Facility ID#(if applicable) • ft ft." MAR u b [l24
W Westmoreland rd King, NC ft. ft. . . . t r-r-,., ?r-=c.=,� ;.-g IRO
Physical Address,City,and Zip ft. ft. " s Yr C^ l,G
uu'e
Stokes •21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude'and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 22.Certification:
36.29076 N 80.40963 W
C 2/16/24
6.Is(are)the well(s)IPermanent or Temporary Signature ofCertified'Well Contractor Date
By signing this form,I hereby cert&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes or__ENo with 15A NCAC 02C:0I00 or 15A 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 I GW-I 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: 325 (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 a"100') construction to the following:
10.Static water level'below top of casing: 40 (ft.) Division of Wafer Resources,Information Processing Unit,
If water level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 .(in.) 24b.For Injection.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
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13a.Yield(gpm) 60 Method of test: sight 24c. For.Water Supply&Infection 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