GW1--03558_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
300 ft, ft. 5 Pm
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased)wells)OR LINER(if ap 'cabk)
Aqua Drill, Inc. FROM TO DIAMETER_ THICKNESS MATERIAL
0 fL 75 ft. 6 in.
Company Name I PVC
393086 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAN1ETIER--' THICKNESS MATERIAL
List ail applicable well construction permits(i.e. UWC,County.State. Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
j!Agricultural ['Municipal/Public ft. R. in.
['Geothermal(Heating/Cooling Supply) QRcsidcntiaI Water Supply(single) ft. R. in,
QIndustriaCCommercial QResidential Water Supply(shared) 1$.GROUT
!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. 22 ft• Chips Poured
13Monitoring I Recovery ft. ft.
Injection Well: ft. - ft.
QAquifer Recharge 10 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
QAquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
®Experimental Technology Q Subsidence Control ft. ft.
DGeothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DFSCRII'rION(color.hardness,so,Vroek type.grain she,etc.)
©Geothermal(Heating Cowling Return) nOther(explain under#2l Remarks) 0 ft, 65 ft• sand
4.Date Well(s)Completed: 6/7/24 Well ID# 65 ft. 345 ft' rock
ft. ft.
5a.Well Location:
Darren Carson ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. • `�/ ' J�`L
332 Trailwood dr West Jefferson, NC ft. ft. ,i itih 1121124
Physical Address,City,and Zip ft. ft.
ashe 21.REMARKS --r17%v...•t4 ..t .""7:':. :rr3
DV:(..r.'._-ki
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lablong is sufficient) 22.Certification:
36.32465 N 81.43835 W
62't^"-2-17—e• jam— 6/7/24
6.Is(are)the well(s)DPermanent or QC Temporary Signature of Certified Well Contractor Date
Br signing this Jonn,1 hereby certijl that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or QNo with ISA NCAC 02C 0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction infannanm,and ecplaor the noun,oi.the copy of this record has been provided to the well owner.
repair under#21 remarks.section or on the hack of this mhrnr
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well S.For Geeprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 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: 345 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i(different(example-30)200'and 2(al/00') constnrction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
if water hotel 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 I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: sight 24c. For Water Supph &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 6 W-I North Carolina Department of Em uonmental Quality-Division of Water Resources Revised 2-22-2016