GW1--02728_Well Construction - GW1_20240507

1-7 Print form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:. .. ' -
•
' • 1.Well Contractor Information:' '
i
• :: - ' •.Cameron:Bazin • • • • • - .14:WATERZONES
_ . - . . - FROM'Well Contractor Name ' ' ' : ' ' O - -DES RIP710
4518-A ..
20gpml ..I.
•
fL fL I f
NC Well Contractor Certif cation Number' . • - 15:OUTER CASING(for multi=cased wells)OR LINER-(if ap•licable)-. • • ..
•.• • •Aqua Drill, Inc• .:.. . • . . . . . DIAMETER-- .. - •
FROM TO' � DIAME R �THICKNESS' .. MATERIAL
_ 0 ' • fL 88 ' ' ft 6• -.i,''•a° ' • . PVC' . . .
Company Name • 16.INNERCASINGORTUBING•(geothermalclosed-loop) ' . -•- . . .
S:well Construction.Permit#: 031 FROM -, TO ' DIAMETER ' -THICKNESS'' MATERIAL -
. List all applicable well construction permits(i.e,WC,Count,.State,"variance,etc) . •. . ff ft i°
3.Well Use(check well use):- • : : -
ft.' ft. in.• .
. . . Water Supply Well:•'. . 17 SCREEN. •'FROM' TO" . . • DIAMETER.. 'SLOT SIZE. 'THICKNESS MATERIAL•'- ...
. . I@ Agricultural'• . . ' :... . ' ' : • Municipal/Public .. • ..ft.• 'H. . . •in.•
. El Geothermal(Heating/Cooling Supply) .['Residential Water Supply(single) , ft ft, •. . . to ', - :
II Industrial/Commercial • . - . : C Residential Water SupPP Y 1 shared
( ). . -18.
. C Irrigation. ' . . . ' - - - • FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT '. '
. : ' Non-Water Supply Well:: • • : :. '• :' 0 ' -27`: ft.' 'Chips . Poured•'.' . ; .
• ft.
• 0Recoveiy I .. .
•. �Monitoring. . .. . .' .. . . .
ft• • f° •
Injection:Well: : -
ft. ft.
- 11 Aquifer Recharge' '- . G Groundwater Remediation. - - . •'• - . .
�'�'( 19.SAND/GRAVEL PACK(if applicable) ,
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. • 7,: ill Aquifer Storage and Recovery- : - : ::QSalinityHarrier_ - - .FROM • TO. . . . 'MATERIAL . ' . . - EMPLACEMENT METHOD • ' .
r:. NI Aquife Test' QStormwater Drainage,•: . . ft ' .. . . . It. - • • • :
. lig Experimental Technology •• QSubsidence Control ft. ' . .ft.. .. '
:. Al Geothermal(Closed Loop) ,.: :: 'CI Tracer..•. ..:. ... ' -20.DRILLING LOG(attach additional sheets if necessary) •
C Geothermal(Heatin Coolin Return .g/ g ) [ Other(eXplaia uade7#21 Remarks) FROM.• ' - TO • .DESCRIPTION(color,hardness,soNroek type,grain size,etc.) -
fa sand,.
4:Date Well(s)Completed::4/23/24. . ' Well ID# - - - 80 • n: 225 'ft . . .
fork�'.. . .. . .. . •
' . . .. . - ..
"tt. ft
. . Brian Holt •. tt. ..ft.
Facility/Owner Name ' ' • . Facility ID#(if applicable) .ft ft. f ••'
t c
�k" "1-_{
638-Fish'river church rd Mt airy, NC . - - . PHrt: : : :; -.,.:�.--. _:' - .
• '.' Physical Address,City,and•Zip . • - , - flif. MAY t O[4. -' - '
.Su . . .. 21.REMARKS. -
.•County'-. . . Panel Identification No.(PIN). - ' ' • Ls:(,J at. : . : • -, .
5b:Latitude and longitude in degrees/minutes/seconds or decimal degrees_:. • .' '
' . '(if well field,one lat/long is sufficient) • . . ., 22..Certification: •
36.42736: • : .'_N_80.694.44 . ' ..w 6a1i-vir�•• C:
;.' 4/23/24.
P r •• Signature of Certified Well Contractor• ' Date
6.Is are the wells d Permanent .or' C1 Temp �.-
. By signing this'form,I hereby certi that the well(s)was(were)constructed in accordance ' '.. .
7.Is this a-repair to tin existing well: .' 1111 Yes or-0No' - . - -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 of 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' •- '
9.TotalW.eli b t dePh elow land surface: 225 . . . '• . ft:
, ( ) •24a. For All Wells:'.Submit this form within 30 days of.completion of well
For multiple wells'list all depths ifdifferent(example-3 200'and 2@l00') - • ' 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"+" ' ' ' 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 push,etc.) -
' ' Division of Water Resources,Underground Injection Control Program;
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,_NC 27699-1636 '
• 13a.Yield(gpm) 26 : .Method of'test: sight • 24c:For Water Supply&Iniec ion-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 io the county health'department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016