GW1--05675_Well Construction - GW1_20240920

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: t`--
1.Well Contractor information: J
Cameron Bazin I4,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 245 It• ft. 15 gpm
NC Well Contractor Certification Number ft. ft.
Aqua Drill, Inc. IS MUTER CASING(for multi-cased wells)OR LINER(if ap licable)
DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 175 ft' I 6 in. PVC
3364 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.UIC,Count•,State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
I@ A CUltllral FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gri C Municipal/Public
ft. ft. in.
lit Geothermal(Hcating/Cooling Supply) IResidcntial Water Supply(single)
1 i Industrial/Commercial ft. ft. in.
I�C Residential Water Supply(shared)
C i Irrigation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 24 it, Chips Poured
VII Monitoring inRecovery ft. ft
Injection Well:
J'Aquifer Recharge n Groundwater Remediation ft. ft.
Ili Aquifer Storage and Recovery I C Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
III Aquifer Test C Stormwater Drainage ft. g• -
ril Experimental Technology ID Subsidence Control ft. ft.
IF Geothermal(Closed Loop) EtTracer 20.DRILLING LOG(attach additional sheets if necessary)
Et Geothermal(Heating/Cooling Return) I'aOther(explain under#21 Remarks) FROST TO DESCRIPTION(color,hardness,soi0toc&type,amain size etc.)
0 ft. 65 ft. sand
4.Date Well(s)Completed: 9/4'24 Well ID# 65 ft, 305 ft
rock
5a.Well Location: ft. ft.
Paula Peglioni rt. ft.
Facility/Owner Name Facility iD#(if applicable) ft. ft. 9 Or•o •d.,,_ e .
1111 Jackson rd Westfield, NC cr. a. SFP 2 0 ?1
Physical Address,City,and Zip ft ft.
stokes 21.REMARKS 1i r
::i.P:� ;'- ^err; -:, f!x>.
-
D
County ate 40 (;)
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:
36.47712 N 80.39311
W 9/4/24
6.Is(are)the well(s)DPermanent or !:YTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certf&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: I C Yes or ONo with ISA NCAC 02C.0100 or ISA 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 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-I 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: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tjdtfferent(example-3 a 200'and 2@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
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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: Sight 24c.For Water Supply&Infection.Wells: In addition to sending the form to
HTH 160Z the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the'county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 2 2016
Revised 2-2 -