GW1--03100_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only'
--1.....7,-.
1.Well Contractor Information:
Cameron Bazin
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 305 ft. ft.
to gpr,
NC Well Contractor Certification Number ft. ft.
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM I TO ( DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 93 ft' I 6 in. PVC
2418 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 it in.
Water Supply Well: 17.SCREEN
0Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
• g Municipal/Public ft. ft. in.
QGcothcrmal(Heating/Cooling Supply) OResidcntial Water Supply(single)
ft. ft. in.
Industrial/Commcrcial QRcstdcnttal Water Supply(shared) -
11. 18.GROUT
Imgation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 27 ft.
Chips Poured
Monitoring ORecovery ft. ft.
Injection Well:
uifer Recharge ft. ft.
A
q g a Groundwater Remediation l
QAquiter Storage and Recove 19.SAND/GRAVEL PACK(if applicable)
ry O Salinity Barrier FROM TO MATEF IA I. EMPLACEMENT METHOD
QAquiter Test OC Stormwater Drainage ft. ft.
QExperimental Technology QSubsidence Control ft. ft.
OGeothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) QOther{explain under#2I Remarks) FROM TO DESCRIPTION tcolor,hardness coil/rock type,g a;n,;rr, tc.t
0 ft. 85 R• sand
4.Date Well(s)Completed: 5/15/24 Well ID# 85 ft. 325 ft.
rock
5a.Well Location: ft. ft.
Jonathan Hudson re. ft.
Facility/Owner;Name Facility ID#(if applicable) ft. ft.
Bandit In Elkin, NC ft. ft. fU/4
Physical Address.City.and Zip ft. ft.
Surry 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Of well field,one latilong is sufficient) 22.Certification:
36.36146 80.79481N ��
W6ar ^ l:?- 5/15/24
6.Is(are)the well(s)CiPermanent or QC Temporary Signature of Certified Well Contractor Date
By signing this fount,I hereby certif-that the tnwills)was(were)conrune'ted in accordance
7.Is this a repair to an existing well: iii Yes or li No with 15.4 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 cop{'of this record has been provided to 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: 325
For multiple wells list all depths if different(example-3(1)200'and 2(a),J00') (ft") 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.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use-4-- 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
12.Well construction method: Rotary above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10
13a.Yield(gpm) 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: 16OZ completion of well construction to the county health department of the county
where constructed.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised___2_22_�_0t6