GW1--01621_Well Construction - GW1_20240313

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '•
• 1.Well Contractor Information: i
i
Cameron Bazin 14.-WATER ZONES • ' • ' :
• Well Contractor Name FROM TO DESCRIPTION . .
205 ft ft 40 gpm
4518-A • 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 . 45 ft. • 6 1 in. . •'PVC.
Company Name ' •
02225 .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. f in. , '
I Well Use(check well use): ft ft. in..
• Water Supply Well:
FROM- . TO • 'DIAMETER SLOT SIZE • THICKNESS . 'MATERIAL
�Agricultural .DMunicipal/Public . ft ft; •• in..
n Geothermal(Heating/Cooling Supply) ['Residential Water Supply.(single) : ft..'.: ft in, .
•I Industrial/Commercial •0 Residential Water Supply(shared),` .18.GROUT.
[Irrigation .. FROM TO '•MATERIAL - EMPLACEM0 f METHOD&AMOUNT: '
Non-Water Supply Well: '0 ft 24 ft• . .Chips .Poured .,_:-i:a L.a-:'''
" Id � '�,
. I Monitoring •'['Recovery
. Injection Well: • ft ft MAI t`Y
•
$ Aquifer Recharge . DGroundwater Remediation • . . w ��C .
19.SAND/GRAVEL PACK(if applicable) . . vi,-_••,`- _..1 •
.In Aquifer Storage and Recovery {r Salinity Barrier . . FROM ' TO ' MATERIAL . EMPLA(`Eh2EBT METHOD 74 -fi 110
Aquifer Test D Stormwater Drainage ft.• ft. veil :`� )G I
.E Experimental Technology •••0Subsidence Control ft.,' ft. .
I Geothermal(Closed Loop) .Tracer' 20.DRILLING LOG(attach additional sheets if necessary)' ' • • V '
Ifil Geothermal(Heating/Cooling Return) •!;t Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,gram size,etc.)
0 ft: : 40 ft. sand '
.
4.Date Well(s)Completed: 5/5/.24 . Well ID# 40 ft ' 225 -ft.. . rock
5a.Well Location: ft fr.. i
Brian Knight rt.:. ft. .
Facility/Owner Name Facility ID#(if applicable) • ft. ft.
346 Bullington Rd Pinnacle,NC ft: ft, '
Physical Address,City,arid Zip ft ft.
Surry • 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:
36.33834 N 80.54034 W
Cmr4•C.J? _ 5/5/24
6.Is(are)the well(s)DPermanent or.[Temporary Signature of Certified Well Contractor ! Date
By signing this form,1 hereby certfr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [Yes or-DNo 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 toithe well owner.
repair under#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.
J
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 (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'and2@I00) 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
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) 40 Method of test: sight 24c.For Water Supply&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. 1
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016 .