GW1--05659_Well Construction - GW1_20240920

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
Cameron_ Bazin 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4518-A 165 ft• ft. togpm
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
0 ft. 85 ft 6 in. PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1923 FROM TO DIAMETER 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.
17. N
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
a Agricultural °Municipal/Public ft. ft. in.
i C Geothermal(Heating/Cooling Supply) in Rcsidential Water Supply(single) ft. ft in.
C Industrial/Commercial �C Rcsidential Water Supply(shared) ft.
GROUT
C Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ff. 21 It Chips Poured
jMonitoring
D Recovery ft. ft
jection Well:
ft. ft.Aquifer Recharge NI Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery I C Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology pC Subsidence Control R. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLINGLOG(attach additional sheets if necessary)FROM TO DESCRIPTION(color,hardness,son/rock tpe,gain size,etc.)
Geothermal(Heating/Cooling Return) ;_C Other(explain under#21 Remarks)
0 ft. 75 f• sand
4.Date Well(s)Completed: 9/5/24 Well ID# 75 ft. 225 ft• rock •
5a.Well Location: ft. ft.
Troy Jessup ft. ft. IT ,? :4 9 k f., 4
Facility/Owner Name Facility iDS(if applicable) ft. ft.
117 Jessup gang In Pilot Mtn, NC ft. ft. S ' 2 0 2'024
Physical Address,City,and Zip ft. ft. !'r-._--r::.-, 'n. t x
surry 21.REMARKS ,-DJe 2v'V
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:
36.46770 N 80.45478 W
n1?-, �_ 9/5/24
6.Is(are)the well(s)JPermanent or QC Temporary Signature of Certified Well 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: i_C Yes or INo with ISA NCAC 02C.0100 or i5A 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 02i remarks section or on the back of this form.
23.Site diagram or additional well details:
8.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 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 multiple wells list all depths ifdifferent(example-3@200'and 2@a 100') 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) 10 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.
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016