GW1--03771_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Cameron Bazin I l4.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 285 ft ft. 25 gpm
ft. ft.
NC Well Contractor C'ernfcation Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licabie)
Aqua Drill, Inc. FROM TO DLAMETER THICKNESS MATERIAL
Company Name0 ft. 455 ft. 6 in. PVC
183208 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS _ MATERIAL
List all applicable well construction permits(i.e.UK'.County..State.Variance.nce.etc.) H. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
0 A CUltUral FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ElMunicipal/Public ft. rt. in.
©Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) —
� ft. ft. in
1._1
0Industrial/Commercial Rcsidential Water Supply(shared) —
"Irrigation GROUT
`r Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 IL 22 ft' Chips Poured
OC Monitoring ©Recovery ft. ft.
injection Well:
ft. ft.
Aquifer Recharge III!Groundwater Remediation _
A fifer Storage and Recovery19.SAND/GRAVEL PACK(if applicable)
g 10 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. . ft.
O Experimental Technology 11Subsidence Control ft. ft.
QGeothetmal(Closed Loop) QC Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) !Other(explain under r#21 Remarks) FROM TO DESCRIPTION(color,hardness soil rack type,gain sirs,etc.)
0 ft. 35 ft' sand
4.Date Well(s)Completed: 6/13/24 Well lD# 35 It. 325 ft.
rock
5a.Well Location: ir, R.
Trevor Wilson ft. ft. ,l 1 J I E .)
Facility/Owner Name Facility!DP(if applicable) ft. ft. ! y",
River retreat lane Sparta, NC ft. ft. JUN 1 2024
Physical Address.City,and Zip ft. ft. 14-40M rzl 71Irr7/1/14•..y iU
pit
Alleghany 21.REMARKS p '(,;i- cP
County Parcel lnuftcaiion No (PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one tat long is sufficient) 22.Certification:
36.52072 N 81.06503 r3tL 6/13/24
W
6.(stare)the well(s)jPermanent or DC Temporary Signature ofCerrticd Well Contractor Date
By signing this form.1 hereby eerufp that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yea or ©No with 15A NCAC 02C 0100 or 15A NCAC 01C 0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain'he nature of the ropy of this record has been provided to the well owner
repair under 421 remarks Section or on the back of this Joan.
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 Wefts 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: 325 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdterent(example-3(a)200 and 2(dlloo')
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
I I.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.auger,rotary, construction to the following:
g cable,direct push,
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 Method of test: sight 24c.For Water Supple&injection Wells: In addition to sending the form to
the addresses) 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- North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016