GW1--03770_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well t_ontractor Name FROM TO DESCRIPTION
4518-A 165 rt. tt. so gprr
ft. ft.
i
VC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Aqua Drill, Inc. FROM 1 TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft* l 59 (t. 1 6 in. PVC
397973 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.Count;.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
°Agricultural °Municipal/Public ft. ft. in.
°Geothermal(HcatingiCooling Supply) °Residential Water Supply(single) —
ft. ft. ill.
°industrial/Commercial °Residential Water Supply(shared) I
18.GROUT
Ii lrngatton FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 25 ft. Chips Poured
0Nlonitonng °Recovery ft ft.
Injection Well:
ft. ft.
Aquifer Recharge If Groundwater Remediation
°Aquifer Storage and Recovery C Salini B 19.SAND/GRAVEL PACK(if applicable)
tyamer FROM TO M.ATER IAL EMPLACEMENT METIIOD
['Aquifer Test °StormwaterDrainage ft. ft.
°Experimental Technology 0 Subsidence Control ft. ft.
°Geothermal(Closed Loop) ',°Tracer
20.DRILLING LOG(attach additional sheets if necessary)
(R Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM TO DESCRIPTION hardness.soil/reek Inn,groin size,etc.)
0 ft. 50 ft, sand
4.Date Well(s)Completed: 6/14/24 Well iD# 50 ft' 205 ft' rock
5a.Well Location: ft. ft.
CMH homes ft. ft. _
-�
FanhtyiOwner Name Facility ID#(if applicable) ft. R. _.. .,�`,r L1 ct/j" L.t
Wallace lane Jefferson, NC ft. ft. -"NI 1 2024
Physical Address.City,and Zip ft. ft.
Ashe 21.REMARKS lrA\ .i.t:P,i;s- y.4;-.y tit
County Parcel Identification No.(PiN) Oa "1 fi'4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat,long is sufficient) 22.Certification:
36.43532 81.46199
N W tom _ 6/14/24
6.Is(are)the wells)°Permanent or °C Temporary Signature of Certified Well Contractor Data
By signing this form,1 hereby c'ertlfj'that the well(s)was(were,constructed in accordance
7.Is this a repair to an existing well: II Yes or Q No with ISA NCAC 02C 0100 or 15.4 NCAC 01C 0200 Well Construction Standards and that
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner
repair under#21 remarks section or on the hark of this limn
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 Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft-)
24a. For All Wells: Submit this firm within 30 days of completion of well
For multiple wells list all depths if different(example-34200 and 2(t.4100')
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 Infection 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) 50 Method of test: sight 24c. For Water Supply& Infection 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 2-22-20I6