GW1--01823_Well Construction - GW1_20240322

' Print Form-
WELL:CONSTRUCTION-RECORD(GW..1) . :For Internal Use Only:.. ,-
.I
1.Weil Contractor Information: r----- -
.Cameron.Bazih . •
• 14._WATER ZONES
Well Contractor Name' •
PROM TO 'DESCRIPTION
4518-A . 700 fr.'. n• • 1 Phil. . ft. ' •ft.' I.
NC Well Contractor Certification Numbs
15.OUTER CASING(far multi-cased wells)OR LINER(if op Ileable)
:Aqua'Drill, Ind. . 'FROM • . -TO, . • •DIAMETER; . THICKNESS '.MATERIAL'. • • ' -
Company Name 0' fL' 70 • 'It'' . 6. • {n.. .
PVC.
0843. ' 16.INNER CASING OR TUBING(geothermal closed-loop)
. •2.Well Constructlon'Permit#: ' • -• .. ' FROM . TO • . DIAMETER' -THICKNESS-• •MATERIAL:. .
.List all applicable well construction permits(lie.WC County,State..Variance,etc.). - ' it.- . In.
.:3.Well Use(check well use)t ' • .: R: . • -ft. .' In.:
•
Water Supply WeUo- 17.SCREEN .
'FROM • `TO• . • • DIAMETER- SLOT SIZE'. THICKNESS- MATERIAL '
. E Agricultural ' • , ; '11 Municipal/Public: , ' it.' • .ft.' In: :
Geothermal(Heating/Cooling Supply); Eltesidentig Water Supply(single) ...iL : • . n• In.
ri Industrial(Comnierciah EC Residential Water Supply(shared) .' •
• 13.GROUT•.
1-E i ruination. • • . . '•FROM • . 'TO. MATERIAL • •EhIPLACEMENr IIETHOD&AMOUNT
•
Non-Water Supply Well • 0' ••'L: • '25.• ti•• .Chips ' j • -Poured
'•E'Monitoring• Recovery. . -ft. ft. -
Injection Well:
• 11l Aq'uifcr,Rccharge' • ®Groundwater Rcmediation. f L I
• 19.SAND/GRAVEL PACK(if applicable)
{I Aquifer Storage and Recovery ,:OSalinity Barrier' - ' FROM' - TO -MATERIAL• , . EMPLACEMENT METHOD . -
•
' I Aquifer.Test• I[ Stornwater Drainage. ft '- it.'-. I
•
• E Experimental Technology . IgSubsidence Control ir: 1L.
.,IA Geothermal.(Closed Loop). 'MTracer . 20.DRILLING LOG(attach additional sheets If necessary)
E Geothermal(Heating/Cooling Return): Other(explain under.#21'Remarks) .FROM TO . DESCRIPTION(eolor,haNaesl sowrnel+ty�e seats eiu:eta)
•O. . .ft::- '.60 it: . sand' '
•4.Date Well(s)Completed:2/1.3/24 •Well ID# 60'. it.. 905 '
.. rock'.
5a.Well Location:. ft. 2 - ".: "''' :.� '•i
Terrie Ann Powell- -ft:- _ tt:. . .:�-�' �" r,
Facility/OvinerName • _Facility1DN(ifapplicable) �• R• MAR L [DLit
• 1824-Rid_ge run rd Boomer,:NC • . •ft..:: • ft.: :
Physical d Zi t . tU .. . W
A dress,City;end p k f: +i;,r+ rr..
Wilkes .' 21.REMARKS •
• 1
• County' - • :Parcel Identification No.)(PIN) . . .
' • 5b.Latitude and longitude In-degrees/mtnutes/seconds or ddnt eal degrees: • - . . . -
'(if well field,one let/long is sufficient) 22.Certification:
.36:07230 •• •N.-8.1:306.. - • R,
:re . ' =2113/24
6..Is(are)the wells) Pernnlnent' .mi.'I[Temporary Sisrtaturc of Certified Well Contractor Date•
• •By signing this form;I hereby certify that the well(s)'nas:(were)constructed In-accordance
7.Is this'll repair to an existing well:.• all Yes •or".1::1No' .. ' with-ISA NCAC 02C,0100 or.ISA NCAC 02C.0200 iYel Construction Standards and that a
if this is a repair,Jill out known well construction hlforinallon and explain the nature ofthe copy-of this record has been provided to the 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-. •
drilled:.. .
SUBMITTAL INSTRUCTIONS ' • '
•
9:Total Well:depth below:land surface: 905:- . - • . •(ft•) 24a. For•All.Wells:''Submit this form:witltin,30 days:of completion of well For multiple wells list all depths Ifdifferent(example=3@200'and2@l00') consttuctiori to.tbe following: I.
10:Static water level below tap of casing:'40 •(tlr:) . Division of Water Resources'Information'Processin Uni
If water level Is above casing,lice"+" S• is
1617 Mail Service Centel,•Rd 2 leigh;NC7699-1617'
11.Borehole diameter:•6- . (in.), 24b.:For inlection'Wellsr.In addition.to'sending the form to the address in.24a.
•
12'Welhconstntction;metho- ROtary above,also submit one copy of this'form within 30.days of completion of well
construction to thdfollowin I •
(i.aauger,mtery'cable;direct push eta). & I
Ii
Division of Water Resources,-Underground Injection Control Program,:
-FOR WATER SUPPLY WELLS ONLY: •1636.Mau'Service Center,Raleigh;NC 27699.1636
•13a;Yield.(gpm) 1-Pint Method of test: Bucket•. , •.'24c.for Water Stipbly&'Inleetlon.Welise.In addition to•sending the form.to-
HTH the address(es) above,.alto'subntibone.copy of this form within•30 days'of
tYpe:.
13b:Disirifeetion . . . :Amount: 160Z'- ; . .completion of well-construction-to the'of ty health.department of the county•
- 'where constructed. .
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' , . . 'Revised 2-22-2016