GW1--03421_Well Construction - GW1_20240610

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only - _ __ _-___
I.Well Contractor Information:
Cameron Bazin 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 145 ft. ft. 25 3pm
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 35 ft. 6 in. PVC
Company Name
403589 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL _
Lot all applicable hell construction permits(Le.UK'.County.State, Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS ! MATERIAL
QAgricultural QMunicipal/Public ft. ft. in.
I'Geothermal(Heating/Cooling Supply) EpRcsidential Water Supply(single) ft. ft. in. i
�-
Industrial/Commercial DResidential Water Supply(shared) y
IS.GROUT
Illrrigation FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: 0 ft• 26 H• Chips Poured
Monitoring QRccovery ft. R.
Injection Well: --4
ft. ft.
Aquifer Recharge
[I Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
°Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
©Aquifer Test DStormwater Drainage ft. ft.
I©Experimental Technology EgSubsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
( g/ g Return) in Other Iexplain under#2I Remarks) -
0 ft• 30 ft• sand
4.Date Well(s)Completed: 5u1 0'24 Well ID# 30 ft• 185 ft.
rock _
5a.Well Location: ft. ft.
Brent Brown ft. ft.
p. r
Facility/Owner Name Facility ID#(if applicable) ft. ft. ; j
Crestview MTN dr Sparta, NC ft. ft. � .,�
�.
Physical Address,City,and Zip ft. ft.
Alleghany z1.REMARKS hOilli tar TC1 Pr6c u
County Parcel Identification No.(PIN) •VrBCh:,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatllong is sufficient) 22.Certification:
36.55763 N 80.94968
W �°,1"'r_i-^ 5/10/24
6.Is(are)the well(s)OPermanent or QC Temporary Signature of Certified Well Contractor Date
By signing this Arm,I hereby certij'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yea or No with ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 remarks section or on the back 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 I 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: 185 (ft.)
24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi Afferent(example-3(4200'and 24)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
Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) 25 Method of test: sight 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: 160Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016