GW1--03428_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
385 rt. ft. 39pm
4518-A
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
0 ft. 80 IL 6 in. PVC
Company Name
019172 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETEF 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. 1'I' r°'
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QC MuntcipaliPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Rcsidcntial Water Supply(single) ft. ft. in.
IndustrialConunercial ['Residential Water Supply(shared)
18.GROUT
Irrigation FROM ' TO MATERIAL EMPLACEMENT METHOD&MOUNT
Non-Water Supply Well: 0 fit• 22 ft- Chips Poured
Monitoring ['Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge
)d Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DC Stormwater Drainage ftL ft.
Experimental Technology (Subsidence Control ft. ft.
Geothermal(Closed Loop) Df Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grata size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under 421 Remarks) 0 fit. 70 It. sand
4.Date Well(s)Completed: 3/25/24 Well ID# 70 ft• 425 ft' rock
ft. ft. ^• ''5a.Well Location: j-
•
Scotty Shore ft. ft.- �C . l +1 I_C
Facility1Owncr Name Facility IDS((if applicable) ft. ft. •JUN 1 1 2024
1116 Mahaney In Yadkinville, NC ft. ft. lak
Physical Address,City,and Zip ft. ft. rr..
Yadkin 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
36.10186 80.63043 W
6 ^ ( ,21� 3/25/24
fC Temporary Signature of Certified Well Contractor Date
6.Is(are)the well(s)DPermanent or
Br signing this faun. 1 hereby certifi.that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QC Yes or DNo widt 15A NCAC 02C.0100 or 15A NCAC 02C 0200 Well Construction Standards and that u
ft-this is a repair.fill nut known well construction infornation and explain the nature of the copy of this record has been provided to the well owner
repair under 1)21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
3.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 1 OW-I is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL LNSTRUCTIONS
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 welts list all depths if-different(example-3f/i 200'and 2o}100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,information Processing Unit,
ifonter level is shove casig,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) 3 Method of test: bucket 24c.For Water Sunplv &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 OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016