GW1--05885_Well Construction - GW1_20241001

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name -
265 ft. ft. 20 gpm
4518-A
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. 90 ft. 6 in. PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1445 FROM TO DIAMETER. THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,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
Ili Agricultural QMunicipal/Public ft. ft. in.
NI Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft. ft. in.
industrial/Commercial QResidential Water Supply(shared) 18.GROUT
DIrngat1on FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 24 ft. Chips Poured
°Monitoring QRccovcry ft. It.
injection Well:
-
ft. ft.
0 Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(if applicat )
QAquifer Storage and Recovery QC Salinity Barrier FROM TO MATF.RIA',. EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage
ft. ft.
®Experimental Technology QSubsidence Control ft. ft. i
OGeothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(eolor,hardness,soil/reek t}pe,znin size.etc.)
QGeothennal(Heating/Cooling Return) QOther(explain under#21 Remarks)
0 ft. 80 ft. sand
4.Date Well(s)Completed: 9/6/24 Well iD# 80 It. 325 ft. rock
5a.Well Location: ft. ft.
CMH greensboro ft. ft. • "`-S..
Facility Owner Name Facility lD#(if applicable) It. It. Q r T 0 1 202 A
164 Mountain top rd Thurmond, NC ft. ft.
Physical Address.City,and Zip
ft. It.
surry 21.REMARKS
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:
36.38017 80.91075 W,
(3 _ 9/6/24
6.Is(are)the well(s)OPermanent or DTemporary Signature of Certified Welt Contractor Date
Si'signing this form,1 hereby certify that the wall(s)was(were/constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with 15.4 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 hack of this form.
23.Site diagram or additional well details:
R.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: 325 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di/jerent(example-34200'and 2(03100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If seater 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) 20 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 2-27-2016