GW1--02440_Well Construction - GW1_20240422

•Print Form
. • ' ' 'WELL CONSTRUCTION'RECORD(GW-1) - . 'For Internal Use Only: -.: : '
1.Well Contractor Information:
Cameron:Bazin ••. •• . • • • -14.• WATER ZONES t:
• • • WellContractorName . • .. .
f
. 39pm
:4518-A:
445. it. t.
tr. ' • tt'. i'
NC Well Contractor•CertificationNumber' _
15:OUTER CASING(for multi-eased wells)OR LINER'(if ap'Hcable)-
•Aqua'Drill, Inc' . . ' • •FROM. . .TO DIAMETER.•. THICKNESS' .MATERIAL , ..
Company Name
. 332674 .. • .•
16.INNER CASING OR TUBING(geothermal closed-loop) ' - . .
" ' .2:Well Construction Permit it: FROM . • TO - DIAMETER. ..THICKNESS.'. •MATERIAL' .
. . • .-List.all applicable well construction permits(i.e.UIC,County,.State,,'Variance,etc) . . -: . ft ft. :''1'1°. .. • . : ''
3.Well Use(check well use):• .. : : • ft.• . • '.ft- , .•.. :• , ; in. • • . : : -
•Water Supply Well: '. CRE DIAMETER" THICKNESS MATERIAL '
17'S EN '
•FROM TO' D • 'SLOT SIZE
Agriculttual ' j(g Municipal/Public . • :. . • .•ft. ft. .. to. . -
, . . _C Geothermal(Heating/Cooling'Supply) Residential Water Supply(single) ' . 'ft ft.. ' In. . . . . .
C Industrial/Commercial ©Residential Water Supply(shared) -18.GROUT-"' _ - -" - '
C Irrigation ' . • • . • FROM. . TO ' . MATERIAL. ' EMPLACEMENT METHOD&AMOUNT . '
• ' Non-Water Supply Well:: • . • •.0 .. • ' .22: '..f.-• Chips .' Poured '' . :
C Monitoring. C Recovery. ft. ft
• .Injection Well:•
• . .l, - .. i=
' C Aquifer Recharge . C Groundwater Retnediation.• .. ' ' '
19.SAND/GRAVEL PACK(if applicable). ''
C Aquifer'Storage Old Recovery- . 7:-USalinity:Barrier•.: • - .FROM • TO. ' .. MATERIAL . •.'EMPLACEMENT METHOD • ' ..
,C Aquifer:Test• ' . . • • .0 StormwaterDrainage _ - : .ft .. ' ft. '• • .
... C Experimental Technology !Subsidence Control .ft. ' . ft. • • •
C Geothermal(Closed Loop) • ,:IC Tracer.. . •20:DRILLING'LOG(attach additional sheets If.necessary)
FROM •TO -. - DESCRIPTION(valor hardness,solUrock type,grain size,etc.). '•-•• .
C Geothermal(Heating/Cooling Return). Other•(explain'under#21.Remarics)
.U '•.• it. 5Q; fL ' sond.' . • .. .
4.Date Well(s)Complete&;3/8/24 .. Well ID# : 50• ft.: ..505 rt ..rock' • ' • •• - ' • • • :
.
.John Blair - . ::ft. •' . ..ft. - • r `-4' V.i'4.: ).. . ••: . •
Facility/Owner Name . . • • Facility:ID#(if applicable) ft; •• • • • y•l'• q r r npp_
601 :Mocksville;.NC. . . .. .. • . .. . .. .
Physical Address;City,and zip . fL fL Ir J(i,%i.:+• i s f S,"C,goo j U. - .
' Davie • . . ' • - • ' - 21:REMARKS, - V v r.A::Jv.
County' ' . Parcel IdentificationNo.:(PII�. .
• ' Sb.'Latitude and longitude in degrees_/minutes/seconds or decimal degrees: • • . ' • •
'ifwell fiel one lat/lon is sufficient)( d' g ) • . 22..Certif�cation:• ..
: • 36.02696. . . - N• 80.61831 . . : . : . - w: . .. .
. 1 :3/8/24 : '
•6.Is(are)the well(s)&Permanent .•or• Ci Temporary Signature of Certified Well Contractor Date
By signing this form;I hereby certifythat the well(s)was(were)constructed in accordance ..:.
' :7:Is this a repair to an existing well: Yes or'12 No • - with:15A NC/IC 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 ofthis 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 Geoprabe/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.details. You may also'attach additional-pages if necessary.
.construction;only 1 GW-1 is needed: Indicate TOTAL NUMBER.of wells •
dulled: • • SUBMITTAL INSTRUCTIONS, • .
•
9..Total.Well depth below land surface:•505 •• fit: •
P ( .) .24ar For All Wells: .Submit this form within 30 days of.completion of well
• - For multiple wells list all depths ifdierent(example-3@200'and 2@100'), -, constructlon 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 .
•
• 11,11orehole diameter 6. : (in.) • 24b.For Iniection Wells;:In.addition to sending the form.M.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: j •
- '(i.e.auger,rotary,cable,direct pdsh,etc.)
- - Division of Water Resources,IUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: . ' • 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) .3 Method of test: bucket 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 types• 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