GW1--03628_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor information:
Cameron Bazin _
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 190 II. ft. GPM
ft. ft.
NC Well Contractor Certification Number
—
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Aqua Drill, Inc. FROM TO I DIAMETER ! THICKNESS MATERIAL
Company Name 0 ft' 77 ft• 1 6 in. i PVC
364723 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.) it. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17,SCREEN
A Cultural FROM i TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Municipal/Public ft. ft. in.
OGcothennal(Heating/Cooling Supply) QRcsidential Water Supply(single)
ft. ft. in.
QC industrialiCommercial Residential Water Supply(shared) 18.GROUT
IImgatiun FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 27 ft. Chips Poured
°Monitoring QRccovery ft. ft.
injection Well:
Aquifer Recharge ft. ft.
Grotmdwater Remediation
uifer Storage and Recovery19.SAND/GRAVEL PACK(if applicable)
A
q g 0 Salinity Barrier FROM TO MATERIAI. EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
QExperimental Technology 0 Subsidence Control ft. ft. -
QGeothermal(Closed Loop) oTracer 20.DRILLING LOG(attach additional sheets if necessary)
QGeothermal(I leating/Cooling Return) QOther(explain under 421 Remarks) FROM TO DFSCR:PTIOV(rotor,hardness,soil/rock type.grain sbe,etc.)
0 ft. 70 ft. sand
4.Date Well(s)Completed: 6/10/24 Well ID# 70 ft' 265 ft
rock
5a.Well Location: R. R. 1 v.`„o L..j V L 1
Justin Shingleton ft. ft.
Facility/Owner Name Facility iD#(if applicable) ft. ft. :JUN 1 3 2624
Fox Den Ln Sparta, NC ft. ft. IFtisaValli , Rr„,r
1.0 ny vr3
Physical Address,City,and Zip ft. ft. -2,-.-,..7)
Allegheny 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one:atilong is sufficient) 22.Certification:
36.50151 81.04217 �)
W 6 ^ L...:1.e7,.- 6/10/24
6.[stare)the well(s)DPermanent or fC Temporary Signature of Certified Well Contractor Date
� Br signing this form,/hereby certify that the s ell(s)Ives(were)constructed in accordance
7.Is this a repair to an existing well: © D Yes or No with ISA NCAC 02C.0100 or ISA,VCAC 02C 0200 Well Construction Standards and that a
If this is a repair fill out known well construction information and explain the nature of the copy of this record has been provider!to the well owner
repair tinder#21 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265
For multiple wells list all depths ifdii different(example-3(d:200'and 2(iP100') ons 24
c
(ft.) 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 water level is above casing,else"+"
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.au er,rotor construction to the following:
g y,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 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 OW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-7%70lr