GW1--03288_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORD GW-1 _ Print Form
I For Internal Use Only:
1.Well Contractor information:
Cameron Bazin
Well Contractor Namc 14.WATER ZONES
FROM TO DESCRIPTION
4518-A 400 ft. ft. t 9Drt
NC Well Contractor Certification Number ft• ft.
tifi
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Usable)
FROM 6 TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' i
80 ft• I in.
0830 PVC
2.Well Construction Permit#: 16 INNER CASING OR TUBING(geothermal closed loop)
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/G County.State.Variance.etc.) ft. fL
.n.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
©Al;riculturalIlli FROM � TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Municipal/Public ft. ft. in.
11 Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
©Industrial/Commercial 111IResid ft• ft. in. - -
ential Water Supply(shared) _
hlmeation 18.GROUT
Non-Water Supply Well: , FROM TO MATERIAL axiom
EMPLACEMENT METHOD&AO
0 ft• Y2 it Chips Poured
Monitoring °C Recovery
Injection Well: ft. ft.
°Aquifer Recharge ft. ft. —
Groundwater Rcmcdiation
°C Aquifer Storage and Recovery OL Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
r Aquifer Test 0 Storrwater Drainage fL ft.
°Experimental Technology °C Subsidence Control —
ft. ft.
Dr Geothermal(Closed Loop) °�-�{T
'Lf^^`�IIracer 20.DRILLING LOG(attach additional,sheets if necessary)
Geothermal(Heating/Cooling Return) !I)Other(explain under#21 Remarks FROM TO DESCRIPTION(color.hardness soil/rock type,grain sirs,etc.)
ill
0 ft. 70 ft sand
4.Date Well(s)Completed: 3/15/24 Well ID# 70 ft. 505 R
rock
Sa.Well Location: ft. ft
Michael Terry n. ft.
Facility/Owner Namc Facility ID#(if applicable ft• ft.
opo s Center Church rd Thurmond, NC ft. ft.
Physical Address,City,and Zip ft. ft.
Wilkes 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) --
36.34934 22.Certification:
80,93080
N
w , 3/15/24
6.Is(are)the well(s)0Permanent or IDTemporary Signature of Certified Well Contractor
Date
Hy signing this form,i hereby Certt•that the wel/(.el was(were)constructed in accordance7.Is this a repair to an existing well:
©Yes or °No with/SA NCAC 02C.0100 or 154 NCAC 122C.0100 Well Construction Standards and Thai a
if this is a repair.fill,uH knowv,well coaruete•Ilan hfrnmNoa and explain Me nature of the copy of this record leer been provided to the well owner
repair ander#21 remarks section or on the back of this form
23.Site diagram or additional well details:
S.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 I GW-I 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: 505
For multiple wells list all depths ifdiffere,n(example-3 rni 200'and 2@a 100') ons a.
c
(fL) For All Wells: Submit this tbrm within 30 days of completion of well
construction to the following:
10.Static water el b l leveelow top of casing: 40
If water level is ah le el use'+ (ft.) 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,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: Bucket 24c.For Water Supply& Injection Wells: In addition to sending the form to
13b.Disinfection type: HTH Amount: 160Z the address(es) above, also submit one copy of'this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Font GW-I Nonh Carolina Department of Environmental Quality-Un•isnm of Water Resources Revised 2-22-2016