GW1--05542_Well Construction - GW1_20240913

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i :
1.Well Contractor Information:
Cameron Bazin - -14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 185 1t ft. 30 gpm
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) _
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 60 R. 5 in. PVC ,
020654 .16..INNER CASING OIt TUBING(geothermal closed coop)-
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cotmty,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
Iti Agricultural ikMunicipal/Public ft. ft. in.
[(Geothermal(Heating/Cooling Supply) MIResidential Water Supply(single) ft. ft. in.
IM Industrial/Commercial °C Residential Water Supply(shared) i&GROUT
i Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 22 n• Chips Poured
if Monitoring . n[Recovery ft. ft.
Injection Well:
ft. ft.
ij'Aquifer Recharge j[Ij Groundwater Remediation
19,SAND/GRAVEL,PACK(if applicable)Ifit
Aquifer Storage and Recovery °C Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test JJ Stormwater Drainage ft. ft.
1 Experimental Technology Eg Subsidence Control ft. ft.
*Geothermal(Closed Loop) *Tracer 20.DRILLINGLOG.(attach adtlitionaL•sf eets if necessary)
[Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,Hardness soiUroxk type,gram sin etc.),
0 ft. 50 ft. sand
4.Date Well(s)Completed: 8/24/24 Well ID# 50 ft• 225 ft* rock
5a.Well Location: ft. ft.
Corey Hethcoat ft. ft. 7<...,,;..a 1 /7
Facility/Owner Name ft. ft. t t�—�.r t6..; of 1,.a,L.•
4Facility IDit(if applicable)
4639 Macy rd Hamptonville, NCa ft. ft. S E P 1 S 2024
Physical Address.City,and Zip ft. ft.
Yadkin 21.REMARKS It, •�:'
IA i,a':51Ou
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.08261 N 80.81151 W
6 f—" 0,t — 8/24/24
6.Is(are)the well(s)JPermanent or EC Temporary Signature of Certified Welt Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or EiNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,full out known well conetnicvtnn information and explain the nature of the copy of this record has been provided to the well owner.
repair under d21 remarks section or on the hack 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
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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 ifd fferent(example-3@ 200'and 2@l00') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If water fetel is above casing.use"+ 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.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 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 2-22-2016