GW1--02479_Well Construction - GW1_20240423

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RrinfForm ���
'• WELL CONSTRUCTION'RECORD(GW-1) :' : For Internal Use Only: .• : ' ..
1.Well Contractor Information: '
.Cameron:Bazin -. 14.WATERZONES i
- Well Contractor Name '. . . FROM -• -TO'. .DESCRIPTION - - -'
. 165 ft it 25 gpm I. I. • • ..
4518-A;
. . ft. ft
- NC Well Contractor Certification Number
15:OUTER CASING(for mold=cased wells)OR LINER(if-ap'lleable) : •.
- _Aqua Drill, Inc.. . - • FROM. . ' TO DIAMETER -THICKNESS' . .MATERIAL .
Co•mpany Name ft ;9l) .ft'.. 6''. .1' in. PVC
3918 • • . _ 16.INNER CASING OR_ TUBING(geothermal closed-loop)`' . '
2.Well Construction Permit#: . FROM . TO - 'DIAMETER. -THICKNESS' •MATERIAL
. . List all applicable well construction permits(.e.UIC,.County State,_Variance,etc) ft tt in•
.3.Well Use(check well:use):- - i • : . • • • '
ft ft* n.
Water Supply Well: _ .
. .. •FROM ' TO . . , DIAMETER' SLOT SIZE. 'THICKNESS. •MATERIAL .
0Agricultural . ' : : . • : .• . ©Municipal/Publie : ..ft- 'ft. : . .-in. . .
•. Geoth'eimal(Heating/Cooling•Supply) .0Residential Water Supply(single) : ._ .ft. ' ft, in '' . . . .
DIndustrial/Commercial : DResidential Water Supply(shared) 18.GROUT '
DC lnigatiOII • • : • . . . .FROM. TO ' MATERIAL EMPLACEMENT METHOD&AMOUNT .
: -.... . Non;Water Supply Well:: .. . .0 .26 f4 Chips' . . Poured •,' . : . .
. :0Monitoring. ' - . •- ' . : • ' :QRecovery_ _ ft. R. _
. Injection:Well: •:• • .
--QC Aquifer Recharge - : .0 Groundwater Remediation.• " ' - - - .'
19.SAND/GRAVEL PACK(if applicable) .
': Aquifer Storage and Recovery- •. -::Q Salinity.Barrier_' - FROM TO- ' .- MATERIAL • -- .'-
:EMPLACEMENT METHOD ' •
QAquifer.Test DStormwater Drainage.... . - ft - .. . - -
f6
. ©Experimental Technology - - Ig Subsidence Control •,ft ' . .ft. • : :
.QGeothermal(Closed Loop) ... .. 12 Tracer.. . ' ... . •20:DRILLING LOG(attach additional sheets if necessary) ... - .
C Geothermal(Heating/Cooling Return) C Other(explain under#21.Remarks) FROM• TO DESCRIPTION(color,hairiness,ion/rock type,grain size.etc.)
g� g ( P0 •• rt . '80 . ..ft sand' .
4:Date Well(s)Complete&4'/8/24 .. - . Well ID#. " ' - 80 . ft '•.225 ft . •rock • - . .
ft. ft i
Sa:Well,Location: . •• l P_..,;, . ,.>r, •
- CMH.Homes it. •.. p.❑‘ •,•q : -
-- Facility/Owner Name _ . . .: ` . :.Facility.ID#(if applicable) .. : .A r..R 2 20 L .. .. : .
• ft' ft .. ,..
' N Friendship rd King, NC • . --- : ft :ft:• ' . .
Physical Address,City, •Zip . -- : - - ft - ft
and : ..L.`.il•'O;:i.,'Jv .1 ' .
• Stokes..
zl REMARKS
. . ' .. . •County . . • •.Parcel Identification No..(PIN)
5b:Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' • : :
(if well field,one lit/long is sufficient) . 22.'Certification: '. 1 - -
36:35324 N 80.28593.... . • :w . . -^ fib
: :4/8/24
t ..
6.Is(are)the wells) .i Permanent , or _C Temporary Signature of Certified Well Contrac or,,` _'Date
:.By signing this form;I hereby cart fy that the we/l(s)was(were)constructed in accordance .' •
7:Is this a repair to an existing well: iil Yes or'EjNo" ' : with.15A NCAC 02C.0100 or15A NCAC-PC.0200 Well Construction Standards and-tat 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:#2I 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 1
• 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'and 2@100)• ' ' • 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'4" ' 1617 Mail Service Center,Raleigh,NC 27699-1617 '
P
11.Borehole diameter: 6 (in.) , 24b.For Infection 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) :25 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016