GW1--05715_Well Construction - GW1_20240920

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information: • . '
Cameron Bazin 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 625 «• ft. 1/2 gpm 1 '
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 1 MATERIAL .
ft. 'ft. in.
Company Name
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,County.State,Variance,etc.) ft, ft. in. .
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
li Agricultural 11 Municipal/Public ft. ft. in.
i0 Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in.
IL Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
CI Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
IL Monitoring id Recovery ft. ft.
Injection Well: ft. ft.
VAquifer Recharge EC Groundwater Remediation _
19.SAND/GRAVEL PACK(if applicable)
JIjiAquifer Storage and Recovery °C Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
IL Aquifer Test EDIStormwater Drainage ft. ft.
A Experimental Technology (°C Subsidence Control ft. ft.
II Geothermal(Closed Loop) EgTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness.sod/rock Npe.grain size,eta)
Jfil Geothermal(Heating/Cooling Return) fC Other(explain under#21 Remarks) 425 ft. 705 ft rock
4.Date Well(s)Completed: 9/19/24 Well ID# ft. ft.
5a.Well Location: ft. ft. {.,r E:;: i o)',• 'r`
John Landini . ft. ft. ' a
C Cn eb +
Facility/Owner Name Facility ID#(if applicable) ft. R. ., t `r az4
3828 Smitherman rd East bend, NC ft. ft. in:CW:4.i`r, �•T,r,f.,:_
Physical Address,City,and Zip ft. ft. L:Z'% `�� +' ''"+
J
Yadkin 21.REMARKS •
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County Parcel Identification No.(PIN) Drill dAApir
I .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 22.Certification:
36.23427 N 80.53756 W
6'I"4d7Q" - 9/19/24
6.Is(are)the well(s)JPermanent or °[Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby cerrfi'that the welt(s)was(were)constructed In accordance'
7.Is this a repair to an existing well: E Yes or E3No with I5A 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 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:.705 (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@200'and 2@l00') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Injection 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) 112 Method of test: bucket 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: 16OZ 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 Revised 2-22-2016