GW1--03146_Well Construction - GW1_20240522

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 385 tt, ft• 4 3pm
ft. ft.
NC Well Contractor Certification Number _
15.OUTER CASING(for multi-cas,d wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Namc 0 ft' 125 ff 6 in. PVC
019696 16.INNER CASING OR TUBING(gtpthermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C.County.State. Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. It. in,
Water Supply Well: 17.SCREEN
FROM TO DIAMETEI SLOT SIZE THICKNESS I MATERIAL
IN Agricultural Munici al/Public
® p ft. ft. in.
li Geothermal(HcatmgiCooling Supply) Residential Water Supply(single) ft- ft. in
MI Industrial/Commercial QResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAI. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 23 ft• Chips Poured
J!Monitoring QRccovery ft. ft.
injection Well:
jB Aquifer Recharge 1111 Groundwater Rernediation ft. R.
Aquifer Storage and Recovery C Salini Bier 19.SAND/GRAVEL PACK(if applicable)
tyarr FROM TO MATERI AI EMPLACEMENT METHOD
li Aquifer Test fStormwater Drainage ft. ft.
iii Experimental Technology (Subsidence Control ft. , ft.
IN Geothermal(Closed Loop) EC Tracer 20.DRILLING LOG(attach additional sheets if necessary)
.11
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soil/rock type,grain sirs,etc.)
0 it. 115 ft. sand
4.Date Well(s)Completed: 5/14/24 Well ID# 115 ft• 425 ft.
rock
5a.Well Location: ft. ft.
Brian Jessup It. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4317 Old 421 Yadkinville, NC ft. ft. 1 1 %.0?4
Physical Address.City,and Zip ft. ft.
Yadkin 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one latilong is sufficient) 22.Certification:
36.12323 N 80.53581 6„"�,z� (3, .....„,... 5/14/24
W
�C Temporary' Signature of Certified Well Contractor Date
6.Is(are)the well(s)10Permanent or
By signing this.form,I hereby certijv rhea the well(a)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ONo with/5A NCAC 02C 0100 or I5A PICA('02C 020(1 Well Construction Standards and that a
If this is a repair.fill out known eel!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 hack of this form.
23.Site diagram of 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 details. You may also attach additional pages if necessary.
constnrction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (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@,100')
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
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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test: Sight 24c. For Water Supply & injection Wells: In addition to sending the form to
the addresses) 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.
Fonn OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016