GW1--02999_Well Construction - GW1_20240520

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only
1.Well Contractor information:
Cameron Bazin
N.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 400 ft. «. ,,Z gpm
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 40 Ct• I 6 in. PVC
0495 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
A cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
©Municipal/Public ft. ft. in.
I Geothermal(Heating/Cooling Supply) DRcsidential Water Supply(single) —
ft. ft. in.
QIndustnal/Commercial (Residential Water Supply(shared) 18.GROUT
( Irrigation FROM TO MATERIA EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 24 ft. Chips Poured
°C Monitoring IN Recovery ft. ft.
injection Well:
�C Aquifer Recharge ft. ft.
IN Groundwater Remediation
Aquifer Storage and Recovery19.SAND/GRAVEL PACK(if applicable)
g QSalinity Barrier FROM TO MATERIAI. EMPLACEMENT METHOD
DAquifer Test I!'Stormwater Drainage ft. ft.
©Experimental Technology ()Subsidence Control ft. ft.
DGeothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) 1�POther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soitlrock type,grain sire,etc.)
0 ft. 30 ft. sand
4.Date Well(s)Completed: 5/3/24 Well ID# 30 ft. 705 ft.
rock
5a.Well Location: ft. ft.
•
Martin custom builders It. ft.
..
FacilitytOwncr Name Facility lD#('f applicable) ft. ft. J 2O2L
149 Whitaker way Pinnacle, NC ft. ft.
Physical Address,City,and Zip ft. ft. i;;t
SUrry 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat'long is sufficient) 22.Certification:
36.3366 N 80.50803
W 62/r'`�z Rom` Cjejt. 5/3/24
6.Is(are)the well(s)CPermanent or ()Temporary
Signature of Certified Well Contractor Date
Br signing this form,I hereby rertif'that the w•ell(s)was(were)constructed in accordance
7.1s this a repair to an existing well: II Yes or QNo 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 tithe GOP)'of this record has been provided Is the well owner
repair under#21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 705 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Gu200'and 2(0100')
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 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:
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) 1/2 Method of test: bUCket 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: 1602 completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016