GW1--01607_Well Construction - GW1_20240313

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• WELL CONSTRUCTION RECORD(GW-1) •.For Internal Use.Only: ;'
1:Well Contractor Information: I �j �}I�
Cameron Bazin 14.WATER ZONES ' "'��\ J. a 2UL-�r
We1lContrac[orNaine '. .FROM . . TO . . DESCRIPTION ,.-. ..,__„�,.f.:r.,I i. . . .
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fL. ft.' liti�,irt,:rcc,1 , .. a
• '.190 20 Gpm [Ytr..,'0,3'3C- •
4518-A ft. ft..' . 1 1 . .
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. '• 70 • ft. -. 6 . . in. . ' . '.-PVC -
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Company Name •
Al7991 •
16.INNER CASING OR TUBING(geothermal closed-loop) •
2.Well'Construction Permit#:• • ' FROM . • TO DIAMETER . •THICKNESS •MATERIAL
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List all applicable well construction permits(i.e.•UIC County,Stale,Variance,etc.) ft.': . ft. :' m.
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3.Well Use(check well use); tc ft. in.-'
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Water Supply Well: . , 17.SCREEN '
FROM -TO ' 'DIAMETER' SLOT SIZE -. THICKNESS . •MATERIAL •
•QAgricultural . . •11]Municipal/Public . ft. - ft. •• •in;,.
QGeotheimal(Heating/Cooling Supply) • QResidential Water Supply(single) . ft. : ft,
QIndustrial/Commercial :QResidential Water Supply(shared)'.-' 18.GROUT
Irrigation - .. . . FROM TO . •MATERIAL . EMPLACEMENT METHOD&AMOUNT.
Non-Water Supply Well: 0 ft..; 2 ft, . Chips•• ! .,Poured
QMonitoring ,©Recovery _• ., -ft.' ••. ft.. • •- •• .
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Injection Well: .
ft.. ft. • • ; •
QAquifer Recharge QGroundwater Remediation .' • • • -
� 19.SAND/GRAVEL PACK(if applicable) •
Aquifer Storage and Recovery ,I_1 Salinity Barrier . FROM. .TO .'• . • MATERIAL . . EMPLACEMENT METHOD . •
QAquifer Test .QStormwater Drainage ft.• . ft. • .
Experimental Technology 1 Subsidence Control ft ft. . .
G Geothermal'(Closed Loop) 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) -Other(explain under#21 Remarks) 0 ft. : 60 ft. sand ' •
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4.Date Wells)Completed: 3/1/.24 . Well ID# 60 ft, 205 ft,• . rock ;.
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•5a.Well Location: • fL ft. .
David Regnery ft.. ft . •
Facility/Ownef Name Facility IV/(ifapplicable) ' . ' fL ft. ,
3148 Spillman Frye Ln East bend, NC ft.: ft.
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Physical Address,City,and Zip ft ft
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•Yadkin 21.•REMARKS - . .
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County Parcel Identification No.(PIN). . I
5b;Latitude'and longitude in degrees/minutes/seconds or decimal degrees: ' .. , '' ''
(if well field,one 1at/long is sufficient) 22.Certification:
36.147 N 80.56093 -
C 0 .3/1/24
.6.Is(are)the well(s){IPermanent or. Temporary Signature of Certified Well Contractor . Date
By signing this form,1 hereby certifr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: . QYes or.QNo, 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 1/21,remarks section or on the back of this form.
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: 1
. .SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 205 (ft.
P ) 24a. For All Wells: Submit this form.within 30 days of completion of well
For multiple wells list all depths it-different(example-.3@200'and 2@!00') construction to the following:
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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 27699-1617
11.Borehole diameter 6 (in.) . 24b.•For Infection Wells: In addition to sending the form to the address in 24a .
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Rotary above,also'submit one copy Of this�fonn 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 C enter,Raleigh,NC 27699-1636
13a.Yield •
20 Method of test: Sight
(gpm) • 24c.For Water Supply'&Infection Wells:-In•addition to sending the form to •
• the address(es) above, also subniit Cone 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
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