GW1--03430_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information: I
Cameron Bazin _
14.WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
4518-A 665 fr• ft. 1 gpm
NC Well Contractor Certification Number ft. ft.
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO ( DIAMETER THICKNESS MATERIAL
0 ft. 80 CL I n.
Company Name PVC
1060 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.U/C,County.State, Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in. _
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OMunicipal/Public ft. ft. 1n.
=Geothermal(Heating/Cooling Supply) EllResidential Water Supply(single) -- —
ft. ft. i.n.
industrialiCommcrcial
Residential Water Supply(shared) —
fmga[ion 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 tt• 22 ft
Chips Poured
Monitoring 0Recovery
ft. ft.
Injection Well:
Aquifer Recharge ©Groundwater Remediation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK(if appliicable)
I.i
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
C Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary) —
Geothennal(I leatingiCooling Return) C Other(explain under#21 Remarks) FROM i TO I DESCRIPTION(color.hardness,soiUroek hpc,grain siia•,etc.)
0 ft. 70 rt. sand
5/17/24
4,Date Well(s)Completed: Well iD# 70 ft. 705 ft.
reek �.�i .� � ,
Sa.Well Location: ft. ft. 4 �+1.+(� ; .
Bonnie Mccann ft. ft. I(IN 1 1 2024 Facility/Owner Name Facility 1D#(if applicable) ft. ft.
3886 Greenhorn rd Roaring river, NC ft. ft.
r
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 lat/long is sufficient)
22.Certification:
36.28171 N 81.00605 �
� W 62 7—,t �" /-:)
r� 5/17/24
6.Is(are)the well(s)lPermanent or Temporary Signature of Certified Well Contractor Date
E_I
Br signing this form,I hereby cert45 that the woli(s)was(tvere)constructed in accordance
7.Is this a repair to an existing well: iI!Yes or ONo with 15.4 NCAC 02C 0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If ins is a repair.fill out known well construction information and explain the nature of the copy of this record hue been provided to the well owner
repair under#21 remarks section ar on the hack of this form.
23.Site diagram or additional well details:
8.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 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: 705 (ft.)
For multiple wells list a/I depths if different(example-3(r�200'and 2(ii),100') 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 tower 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;firm 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
I3a.Yield(gpm) 1 Method of test: Bucket 24c. For Water Supply& Injection'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: 160Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016