GW1--02932_Well Construction - GW1_20240513

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WELL CONSTRUCTION RECORD(GW-1) --
I For Internal Use Only: If...,-- ----,--;._
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES ( ..
Well Contractor Name FROM TO DESCRIPTION
4518-A 185 ft. ft. 40 9pm '
NC Well Contractor Certification Number ft. ft.
Aqua Drill, inc. 15.OUTER CASING(for,multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' I115 ft: I 6 ' in. I PVC
0496 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.) ft. ft. in.
3.Well Use(check well use): ft. ft. in. -
Water Supply Well: 17.SCREEN
AgriculturalFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�t Municipal/Public ft ft. in.
11 Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single)
ft. ft. in.
Industrial/Commercial °C Residential Water Supply(shared)
Irrigation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft* 26 R• Chips Poured
iiMonitoring ()Recovery R. ft.
Injection Well:
Iii Aquifer Recharge ° ft. ft.
Groundwater Remediation
lit Aquifer Storage and Recovery [ Salinity Barrier .19.SAND/GRAVEL PACK(if applicable) -
FROM TO MATERIAL EMPLACEMENT METHOD I7I Aquifer Test ID Stormwater Drainage ft. ft.
IN Experimental Technology E3subsidence Control ft. ft.
II Geothermal(Closed Loop) I°IC Tracer 20.DRILLING LOG(attach additional sheets if necessary)- - -
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock hoe,grain size.de.)
. 5/6/24 0 ft• 100 ft. sand
4.Date Well(s)Completed: Well ID# 100 ft- 225 rt•
rock r- m
5a.Well Location: ft. ft. 1:•:•L.
Martin custom builders - fL ft.
FacilitylOtvnerName Facility ID#(if applicable) ft. ft. �Yt}j�� 1 CU[4
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162 Cowboys way MT Airy, NC ft. ft.
Physical Address.City,and Zip ft. ft. ,h.(v ;•v'' °.;l;
c . i`.J
surry - 21.REMARKS _ -
C0unt Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
36.52653 N 80.51766 22 Certification:
W 6/?-4.z-o_^ 1 5/6/24
6.Is(are)the well(s)JPermanent or Temporary Signature of Certified Well Contractor Date
ing this
I hereby car
accordance
7.Is this a repair to an existing well: mC Yes or EiNo with t ISA NCAC 02C.0100 or ISArNCAC 02C.020that the wa (0)Well Constructionwas(were)constructed 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 N21 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
9.Total well depth below land surface: 225
For multiple wells list all depths ffdii different(example-3@200'and 2 t@e t 00') (R) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 40 (ft.) �,
If water level is above casing,use"p Division of Water Resources;Information Processing Unit,
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
12.Well construction method Rotary • above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary, construction to the following:
g cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 40 Method of test: sight 24c.For Water Supply&Infection Wells: In addition to sending the form to
HTH the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 160Z completion of well construction to the'county health department of the county
where constructed. i I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016