GW1--02503_Well Construction - GW1_20240422

•
Print Form
WELL CONSTRUCTION RECORD(GW-1) - For Internal Use Only: '
1.Well Contractor Information: '•
. .
.Cameron Bazin • . . ' 14.WATER ZONES ,
Well Contractor Name FROM•. _ TO - DESCRIPTION - - ,
4518-A ft
205.. - ft. 4ogpm l '
ft. H. •
•
NC Well Contractor Certification Number • 15:OUTER CASING(for multi=cased wells)OR LINER(if ap•licable) •
' Aqua Drill, Inc. - E
ft n
•FROM TO DIAMETER THICKNESS .MATERIAL
Company Name 0 150 ft. s i • • PVC
398430 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.) It. ft. in.
3.Well Use(check well use):- ft. rt. in.
' 17.SCREEN '
Water Supply Well: FROM ' TO DIAMETER SLOT SIZE. 'THICKNESS. MATERIAL.• ' •
Ili Agricultural QMunicipal/Public ft it to.
n Geothermal(Heating/Cooling Supply) .QResidential Water Supply(single)•' ft it is
NI Industrial/Commercial• QResidential Water Supply(shared) - 1S:GROUT"'
L Irrigation . . .FROM : TO ' . MATERIAL . EMPLACEMENT METHOD&AMOUNT '
Non-Water Supply Well: . . 0 f.- 28. ft. Chips • Poured • ,
®Monitoring - _ - • Recovery • - - ' . ft.- . ft. . . . ..
Injection Well: •
• ft, • : ft •'
•
In Aquifer Recharge . - Q Groundwater Remediation - - •• - 19.SAND/GRAVEL PACK(if applicable). -
.
IDA uifer Storage and Recovery . QSalinityBarrier . ' . FROM TO. . . MATERIAL EMPLACEMENT METHOD
' ®Aquifer.Test' QStormwater Drainage ft ft. •
•
. 11i Experimental Technology MI Subsidence Control .ft ft. •
Ei Geothermal(Closed Loop) .. .. . .. Tracerr . .. • . . : .. 20:DRILLING LOG(attach additional sheets if necessary) - •-
C Geothermal(Heating/Cooling Return) Q Other(explain under#21.Remarks)' FROM• TO DESCRIPTION(color,hardness sofOr«k type,grain size etc.)0 .. ft• . 140 ft sand . .
•
4.Date Well(s)Completed::4/15/24 Well ID# 140 ft 265 ft. rock
5a:Well Location: . . ft ft
• Josh Caddo .• . rt rt •
Facility/Owner Name, Facility ID#(if applicable) : it it .`C....;t-.., o i i; :1..":'J ,
10448 Glade Valley rd Ennice, NC « ft A 1)•
. .. ft. - ft. r'1i111.4 G 2024
Physical Address,City,and-Zip'
Allegheny : - • - 21.REMARKS ' - Er.`,:...-...... .s ;: . -
County - • Parcel Identification No.(PIN) . -. ' l<•
5b.Latitude and longitude in degrees/Minutes/seconds or decimal degrees: • -
• (if well field;one lat/long is sufficient) • 22..Certification: •-
. 36.55439 N. 80.93413. �,
.. . � _:_ 4/15/24. -
6.Is(are)the well(s){JPerm Canent or Temporary . Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7:Is this a repair to an existing well: QYes Or QNo • with:15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
. . . If this is a repair,fill but 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 GeoprobelfPT 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 if d jfeient(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 live!is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
•
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 pat,etc.) .
1
' Division of Water Resources,;Underground Injection Control Program, •
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 40 • 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