GW1--05544_Well Construction - GW1_20240913

W CONSTRUCTION RECORD(GW-1) For Internal Use Only: , ; 1- ������
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1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A
185 ft. ft. 20 9pm
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-eased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 35 ft• 6 in. PVC
019867 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.WC.Coantt•.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
ricultural
OMunicipaUPublic ft, ft. in.
thermal(Heating/Cooling Supply) ; iResidential Water Supply(single) ft. in.
strial/CommercialationWater Supply Well: 'J[r(i Residential Water Supply(shared) 18.GROUTFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft' 24 ft- Chips Poured
itoring �C Recovery ft. ft.Well:
ft. ft.
C Aquifer Recharge oC Groundwater Remediation
[Aquifer Storage and Recovery
19.SAND/GRAVEL PACK rfapplicable)._. .
Q g ry Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Et Aquifer Test �C Stormwater Drainage ft. ft.
E.Experimental Technology DC Subsidence Control ft. fr.
".Geother:al(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets If necessary) __
f ImGeothermal(Heating/Cooling Return) Other(explain under#2l Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
0 ft, 25 ft• sand
4.Date Well(s)Completed: 8/23/24 Well iD# 25 ft• 225 fr.
rock
Sa.Well Location: ft. ft.
Ryan Phipps ft. ft. 9 m
Facility/Owner Name Facility 1Dk(if applicable) ft. ft. '-®9.,i
4437 Rena rd Hamptonville, NC ft. ft. SEP 1 .:1 lUL4
Physical Address.City,and Zip
Yadkin 21.REMARKS ft. ft. IGf^,;,tee;irk s
: ..
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:
36.16780 N 80.83385 W
62'r't'7.J9-^ 8/23/24
6.Is(are)the wells)JPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert j5'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DC Yes or E3No with ISA NCAC 02C.0100 or 114 NCAC 02C.0200 Well Construction Standards and that a
If this is 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 buck 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
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 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 imiltiple wells list all depths ifdijjerent(example-3 ct 200•and 2@100') construction to the following:
10.Static water level below top of casing: 4() (ft.) Division of Water Resources Information Processing Unit,
If eater level is above casing.use + 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.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.nutter,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&Injection 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. i 1
Fora GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016