GW1--01900_Well Construction - GW1_20240325

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Ba4II1 •14.WATER ZONES . . •
Well Contractor Name •"' .�• FROM TO DESCRIPTION
3:_1_ ••i ...l i is,-,- 160 ft ft 20 gpm I
4518-A '' r i ;' A
ft ft' . .
NC Well Contractor Certification Number MAR 2 L► 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. 2024 FROM ' TO.. : DIAMETER.: • THICKNESS MATERIAL..
• ITix=,:=.::,:;.. 0 ft. . 120 . ft •• 6 ; in. ''PVC
Company Name ` ,1:'^;�� �r . .
03484 �iZ rt,ram'JG m 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. . hi.
•
3.Well Use(check well use): ft. ft in
1 Well: 17.SCREEN • '
Water Supply y FROM , TO DIAMETER SLOT SIZE THICKNESS . -MATERIAL '
Agricultural Municipal/Public ft. ft: in. .
)d Geothermal(Heating/Cooling Supply) QResidential.Water Supply(single) ft... • fa in
11 Industrial/Commercial •0 Residential Water Supply(shared) • •.18.•GROUT. ' . . . '
L Irrigation .. FROM TO ' •MATERIAL EMPLACEMENT METHOD&AMOUNT
.Non-Water Supply Well: 0 ft26 ft . _Chips ' Poured •
E Monitoring •IIM Recovery ft ft:.
Injection Well: •
ft.. ' ft. - . •
Ill Aquifer Recharge Groundwater Remediation • . ' •
• ' '
' 19.SAND/GRAVEL PACK(if applicable)
le Aquifer Storage and Recovery ,i Salinity Barrier . FROM. . .TO ' •MATERIAL- EMPLACEMENT.METHOD •
1g Aquifer Test IDStormwater Drainage ft. ' ft.: .
.E.Experimental Technology D Subsidence Control ft. ft. . . ;
•
11 Geothermal(Closed Loop) .OTracer • • 20.DRILLING LOG(attach additional sheets if necessary) '
•NI Geothermal(Heating/Cooling Return) •Other(explain under#21 Remarks) FROM To DESCRIPTION(rotor,Hardness solurock type;emir size.ere.) •
.0 ft• . 110 ft. sand •
4.Date Well(s)Completed: 3/14/24 Well ID# • 110 ft 265 ft•• rock
5a.Well Location: ft ff
Rocky Horton ft.. ft. .
Facility/Owner Name Facility ID#(if applicable) ft. fL'
Hollow and hill In MT Airy, NC • ft. ft. • •
Physical Address,City,and 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:
36.54942 N 80:69046 �,
^ � 3/14/24
6.Is(are)the well(s)IPermanent or DTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes •or-INo with 15A NCAC 02C.0100 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#11 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: 265 • . . (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdi different(example-'3@a 200'and 2@100')• construction to the following:
10.Static water level below top of casing: 04 (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
i
• 13a.Yield(gpm) 20 Method of test: sight • 24c. For.Water Supply&Injection 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