GW1--05439_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only! 1
1.Well Contractor Information:
Cameron Bazin ' 14.WATERZONES
Well Contractor.Name
FROM TO DESCRIPTION
470 ft. ft.4518-A 25 gpm i
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap 'feeble)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 75 ft. 6 in. PVC
Company Name
1185 16.INNER CASING OR TUBING(geothermal closed-loop)
Z.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. H. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS ' MATERIAL
QAgricultural QMunicipal/Public ft. ft. in.
®Geothermal(Heating/Cooling Supply) QRcsidential Water Supply(single) ft ft in. -
Qlndustrial/Commercial QRcsidcntial Water Supply(shared) 18.GROUT _
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 23 ft. Chips Poured
DMonitoring I Recovery ft. ft.
Injection Well: ft. ft.
IDAquiferRecharge QGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
QAquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
QAquiter Test QStormwater Drainage ft. ft.
QExperimental Technology Subsidence Control ft. ft.
QGeothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock Ispe,grain size.etc.)
QGeothermal(Heating/Cooling Return) QOther(explain under#21 Remarks)
0 ft. 65 ft. sand
4.Date Well(s)Completed: $/20/24 Well ID# 65 ft 485 ft. rock
5a.Well Location: ft. ft.
Scott felts ft. ft. • r
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
132 Lonesome pine rd Purlear, NC
ft. ft. SEP 0 9 zap,
ft. ft.
Physical Address.City.and Zip
Wilkes 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat'long is sufficient) 22.Certification:
36.17660 N 81.34396 µ,
��►^-Li7.1--^ 1..�_-- 8/20/24
6.Is(are)the well(s)f Permanent or QTemporary Signature of Certified Well Contractor Date
By signing this flint',1 hereby certi(iv that the well(s)was(were)constructed in accordance
7.1s this a repair to an existing well: @Yes or QNo with/SA NCAC 02C.0100 or 15A NCAC 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 provided to the well owner
repair under#21 remarks section or on the hack of this form.
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: 485 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(0200.and 20,10(') 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) 25 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
t3b.Disinfection type: HTH Amount: 16OZ completion of well construction to the county health department of the county
where constructed.
Font GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016