GW1--02488_Well Construction - GW1_20240423

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Print Form
' 'WELL CONSTRUCTION'RECORD(GW-1) " • :••• For Internal Use Only: ;'.: I ' • . :
1.Well Contractor Information: '
- • .Cameron.Bazin• • .. . _. • . . ••_ 14.WATER ZONES". i;i
Well Contractor Name FROM •TO . - - . .DESCRIPTION
•
• •
3a5.. ft ft • .gpm 1_
45.18-A
• • • . •• ft.. . ft; • • - • . .
•
•
NC Well Contractor Certification Number • IS:OUTER CASING(for multi-cased Wells)OR LINER(If applicable)• -- '
- .Aqua:Drill, Inc.. . . .. . ..FROM TO� • � DIAMETER � �THICKNESS' MATERIAL
Company Name fL 80 ft. 6. :in. PVC .
- •
•
019172 . - 16.INNER CASING OR TUBING(geothermal closed loop)' • "
2.Well Construction Permit#: FROM . TO -. . 'DIAMETER .THICKNESS- MATERIAL
. List.al!applicable well construction permits(i.e.UIC,County,State,,'Yariance etc.)' • .ft. ft., .io' .. . - : : : ,
• 3.Well Use(check well use): ' : • ;
ft' ft' in.
-WaterSupply Well:.. . - • •.. . . _ • .. - . _ . . :SCREEN-. ._. -.. _ • -
. . . . FROM' -TO' • DIAMETER' .SLOT SIZE 'THICKNESS. -MATERIAL_ ' . .
0Agncultural. . •' _.. . Municipal/Public . ' ... . • ft. 'ft.. . . •In, . . . -
CGeothermal eatin Conlin 1
.� � � S Su PP y) :DResidential Water Supply(single) ' " ' '. . 'tt ft• •
©Industrial/Commercial • • .QResidential'Water Supply(shared) , 18.GROUT " '
hlrrigation• • .. - • ' • • ' . - .FROM. . TO ' . MATERIAL. EMPLACEMENT METHOD&AMOUNT . '
. Non;Water Supply Well:: - - .0 ft— .22' :, ft.- Chips.' . . . Poured• • . .
•:: Monitoring ' :DRecovery. ' ... ft. :.ft. . • . .. .. . . :
Injection Well:• : : '
Aquifer Recharge • - • ' - Groundwater Reme diation " •' ' ' • ' '- ' - - ' - • • - • "
19.SAND/GRAVEL PACK(if applicable). •'- "''
❑IC Aquifer Storage and Recovery " • -.:Q SalinityBarrier-.: " • .FROM - TO. ." •MATERIAL . . •- EMPLACEMENT METHOD •• ' ..
Aquifer:Test . ' ' • ' ILt Stormwater Drainage•' . ft:
C . - ft- . :•• -
.' , Experimental Technology 111 Subsidence Control ' . :.ft- ft.. • .. '' '
.[Geothermal(Closed Loop) •: It Tracer.. -20:DRILLING LOG(attach-additional sheets if necessary)
C Geothermal satin Cooliti Return) C Other ex lain under#21.Remarks FROM-' TO .DESCRIPTION(color,hardness,soiUrock type,grain aize,et A, .1. : ..
{"I (x �! g PM ( P )
0:".:
.' . . to 3/25/24 70 • •ft ''425 'ft 1 . --" ;.-.,r.. •4.Date Well(s)Completed: : Well 10)# � •• . 'rook . . 6:.:; :.... ;.•..: : �';�._ •.. .
5a:Well Location: : —ft. .. . . ft. . i S'.+ss,c'r t_;..t 1!'1 L.• .. .
f
" •.Scotty.Shore . • .. . . �APR' 2.• :..COZ4 ' ... .
: .. Facility/Owner Name ' .' ' .. : ;.Facility ID#(if applicable) ' ' • ft • ft • - • '
1.116 Mahaney In Yadkinville, NC.
Physical Address,City,and Zip
Yadkin ..
21 REMARKS
County' • :. .. . •: Parcel Identification No..(PIN) • '• •
5b.Latitude and longitude in degrees/Minutes/seconds or decimal degrees: : : : : : ' -
(ifwell field,"one lit/long is sufficient). .. 22..Certification: • •
36:1018fi. N80.63043 . w ". C r Ge• • • 3/25/24
t
6:Is(are)the well(s)jPermanent or _C Temporary Signature of Certified Well Contractor Date
.By signing this form;I hereby certb'that the well(s)was(were)constructed in accordance
7:Is this a repair to an existing well: jig Yes or No 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:#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 :•
constiuction,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.Totalwell depth below land surface: 425 . • '(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 alloys casing'use"+' ' 1617 Mail Service Center,Raleigh,NC 27699-1617 '
• 1
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: -
construcflonao the following: -
(i.e.auger;rotary,cable,direct push,etc.)
Division of Water Resources,-IUnderground Injection Control Program; . '
• FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cr.enter,Raleigh,NC 27699-1636
. 13a.Yield(gpm) .3 Method of test: bucket 24c:For Water Supply&Iniectloa:Wells: In addition to sending the form to-
• the address(es) above, also subnntlone 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