GW1--06140_Well Construction - GW1_20241014

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 305 ft. f1 25 gpm
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
Company Name 0 ft. 60 ft. 6 in. I PVC
4062 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. ft. in.
Water Supply Well: 17.SCREEN
� FROM TO DIAMETER SLOT SIZE THICKNESS _ MATERIAL
I!Agricultural '01Municipal/Public ft. ft. in.
iii Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in. •
Al ndustrial/Commercial DC Residential Water Supply(shared) 18•GROUT
r I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 22 ft.
Chips Poured
Ili Monitoring l Recovery ft ft.
Injection Well:
ft. ft.
JPI Aquifer Recharge lii Groundwater Remediation
19..SAND/GRAVEL PACK(if applicable)
EPAquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD -
FlAquifer Test OC Stormwater Drainage ft. ft.
II Experimental Technology °Subsidence Control ft. ft.
Jai Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
II
Geothermal(Heating/Cooling Return) ®C'iOther(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness soil/rock ppe grin size,sac.)
0 ft- 50 ft• sand
4.Date Well(s)Completed: 9/30/24 Well ID# 50 ft 345 ft rock
5a.Well Location: ft. ft.
April Shelton ft. ft. a - ' • > i' 1
Facility/Owner Name Facility 1Db(if applicable) ft. ft.
Barr farm rd King, NC ft. ft. U C i g ' 2024
Physical Address,City,and Zip ft. ft. I1 r0. :� '_ t
Stokes 21.REMARKS f•.,.:' :' _
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: ,
36.306 N 80.32163 W £ L. 9/30/24
,ji lTemporary Signature of Certified Well Contractor Date 6.Is(are)the well(s)OPermanent or
By signing this form,I hereby certif.:that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Ip Yes or ligNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill nut knoum well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 1121 remarks section or on the bock 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: 345 (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 a 00'and 2@J00') 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 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) 25 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016