GW1--05438_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin I4.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
185 ft. ft. 20 gpm
4518-A rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Hcable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 60 ft' 6 in. PVC
Company Name
1179 16.INNER CASING OR TURING(geothermal closed-loop)
2.Well Construction Permit# FROM ro DUME'rER _ THICKNESS MATERIAL
List all applicable well construction permits(i.e. UiC.County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17,SCREEN
FROM TO DIAMETER I SLOT SIZE 1 THICKNESS MATERIAL
Aancultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) PResidential Water Supply(single) ft. ft. in.
= IndustrialConunercial D Residential Water Supply shared
pp y(shared) 18.GROUT __
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 25 ft. Chips Poured
Monitoring DRecovcry ft. ft.
Injection Well:
ft. ft.
'Aquifer Recharge ©Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ❑IC Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DC Stonnwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft. j
Geothermal(Closed Loop) Or Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock Ope,grain sire.etc.)
Geothermal(Heating/Cooling,Return) nOther(explain under rt21 Remarks)
0 ft• 50 ft. sard
4.Date W'ell(s)Completed: 8/27/24 Well iD# 50 ft' 225 R' rock
5a.Well Location: ft. ft. 1.--
' v--,ry_.'• /t'
Garcia Wallace ft. `� 'L, V/ C ,( .
Factlity'Owncr Name Facility IDtt(if applicable) ft. ft. r t' ll) (a ,.4
Sweetwater rd Boomer, NC ft. ft.
ft. ft.
Physical Address.City.and Lip
Wilkes 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lot long is sufficient) 22.Certification:
36.07599 N 80.30958 W ,�, (�, — 8/27/24
6.Is(are)the well(s)JPermanent or �C Temporary Signature of Certified Well Contractor Date
Br signing this form.i hereby certijv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: li Yes or ONo with iSA NCAC 02C.0100 or ISA h'CAC 02C.0200 Well Construction Standards and that a
II this is a repair fill out known well construction initrmation and explain the nature of the copy al-this record has been provided to the ic/I owner.
repair under 421 remarks section or on the hack of this(Pim.
23.Site diagram or additional well details:
S.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 I 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: 225 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di/Jerent(example-34200'and 2(r4I00') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
(Twitter level is above casing.use-+ 1617 Mail Service Center,Raleigh,NC 27699-1617
i1.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) 20 Method of test: sight 24c. For Water Supply& iniection 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.
Ilon.i G11'-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016