GW1--02489_Well Construction - GW1_20240423

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Print Form
'WELL CONSTRUCTION RECORD(GW-1) - : • For Internal Use Only:- ; ..
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.. •• 1.Well Contractor Information: . " " - ••' • ;••'••
Cameron Bazin - -•
>i4.WATER ZONES i;''z
FROM" ODESC N
- Well Contractor Name -
- -. _ ' .. - 1 Quartl..
'4.818-A. 4s5
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•
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NC Well Contractor Certification Number - --15.OUTER CASING(for multi-cased wells)OR LINER(if ap'lcable) ' •-
Aqua ua'DriII, IncInC.. . - . . .FROM. .' TO DIAMETER. THICKNESS' MATERIAL
Co an Name • . . -• 0 • ft' •130 ft: _.S . : , in.• . :: •. • - I PVC - • •..
Y' • G • 16.INNER CASING OR TUBING(geothermal closed-loop)'- - - '
�Z:Well Construction Permit#:'019 54 ` ' - • FROM .', TO - .. . DIAMETER - ..THICKNESS. -. MATERIAL ' . :
. . , ' .:List.all applicable well construction permits(i.e.UIC,.County,State,:Variance,etc.) ..ft- . : ft, • - in. .. :.
: .3.Well Use(check well use):• • • • ft.: , ' St.• , • ' in. .• • .
Water Supply Well: 17:SCREEN
.. -FROM TO' . DIAMETER.. 'SLOT SIZE.. THICKNESS. MATERIAL • .
. . ig Agricultural-• • ' . Municipal/Public : ; "..fI: • - 'ft..` iu._ . - ' '
. l!Geothermal(Heating/Cooling'Supply) Okesidential Water Supply(single) : . ft.
'ft
. '._ in. . . .
. • : QIndustriallCommercial • .- • QResidentialWater Supply(shared) • 18:GROUT" ' '
�C Irrigation.
- FROM - TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
. : • :.:.• . Non-Water Supply Well:: • •• - " • •.0 • • . 24• ,. •Chips'' Poured .' . : ,
fL fL
. . :aMonitoring. : -" " . : - ' :0Recovery.- . . • . - .H. • •H. • .
" •:Injection Well: . . . .•
QC Aquifer Recharge " • • ©C Groundwater Remediation : ' fL• •:fL • • ,.
19.SAND/GRAVEL PACK(if applicable) .
':'.[:• Aquifer Storage and Recovery' W Salinity Barrier.'.: . • .FROM - TO. " . MATERIAL ' •• EMPLACEMENT METHOD • • ' "
QAquifer:Teat••" OStormwaterDrainage ' . : . • • •ft fL • . . • • • . •
.®C Experimental Technology •' • . • Subsidence Control ' 7,ft. ft.
QGeothermal(Closed Loop)• ,: _lTracef.. . ' •20:DRILLING LOG(attach additional sheets if.necessary) ' .. ' . . •
I Geothermal(Heating/Cooling Return). [C Other(explain under#21-Remarks) FROM TO DESCRIPTION(eotor,hardness eoivrack type grain size,etc.).
4.•Dat •
e Well(s)Completed:4'/2/24 Well ID#. . '12•0 ft.. •••625• -fL ' - . - --
: ' P . ._ ..rock !:: . . • . .
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5a:Well Location: %1 :�^
• . Mark Coble.- . • • fL :ft- - • ,• •
, . .- . -.-. . . . : : : .
Facility/Owner Name • .Facility"ID#(if applicable) • _—
. .. � ft, fL ,
APR.G•: cUL4
42;12.Emma's Way.East bend",.NC. . .. . • ._ ft.. " fL. • . " :
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Physical Address,City,and Zip ' - .. : •rsc':c fv`3 C...
ft'. fL
Yadkin 2i:REMARKS
County : Parcel Identification No..(PII�.
' i• Sb.;Latitude and longitude in degrees/minutes/seconds or decimal degree!: • • • '
(if well field,one let/long is.sufficient). ' . 22..Certfi n:catio .,• . -
. 36:13148. N" 80.49222 '
. . ... . ., 4/2/24
:• ' 6.Is(are)the well(s){Permanent or 0Temporary..
Signature of Certified Well Contractor•. : . Date
" ' . . . . ..By signing this form,•I hereby cernk that the well(s)was(were)'constructed in accordance
.7:Is this a repair to an existing well: •QYes 'or a No' - -with;ISA NCAC 02C.0100 or ISA 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
• : • . construction,only 1-GW-1 is needed:-Indicate TOTAL NUMBER.of wells •construction.details. You may also attach additional pages if necessary. . - -
drilled: . . - .
.. � ,'.$ MITTAL INSTRUCTIONS,•
w 625
• 9.. otal well depth belo land surfa• ce:. f.
) 24a. For All Wells: Submit this form Within 30 days.of.completion of well
- •- For multiple wells list all depths if di ferent(example-3 200'and 2@l00'), • construction to the following: •• I
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,'Borehole diameter: 6. • (in.) 24b.For Injection Wells::In addition to sending the form:to:the address in 24a .• •
• ' Rotary- . - ' • above,also submit one copy of this forth within 30 days of completion of well
12.Well construction method: c c o the following:
•
(i.e.auger,rotary,cable,direct push,-etc.) -•• -
.. on
Division of Water Resources, `Underground Injection Control Program,
- FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Quart Method of test: Bucket 24c:For Water Supply&Injection.Wells:. In addition to sending thee-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 hi 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