GW1--06254_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: i e '-
1.Well Contractor Information:
Cameron Bazin 14.WATERZONES
FROM TO 'DESCRIPTION
Well Contractor Name 100 ft• ft. 40 m
ft.
4518-Aep
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 1 MATERIAL
0 R. 75 ft. 6 in. PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 401809 FROM TO OtAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC.County.State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fig Agricultural ®Municipal/Public ft. ft. in.
I Geothermal(Heating/Cooling Supply) DResidcntial Water Supply(single) ft. ft. in.
1ilndustrial/Commercial ( Residential Water Supply(shared) 18.GROUT
(_[Irrigation FROM TO MATERIAL EMPLACEMENT METHOD.&AMOUNT
Non-Water Supply Well: 0 ft. 22 ft' Chips Poured
jliMonitoring 11 Recovery ft. ft.
Injection Well: ft. ft.
a Aquifer Recharge I Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
i(tj[Aquifer Storage and Recovery I C Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
MI Aquifer Test 1:11 Stormwater Drainage ft. ft.
II Experimental Technology D Subsidence Control ft. ft.
Mi Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soil/rock type.grain size.etc.)
C Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) 0 ft. 65 ft• sand
4.Date Well(s)Completed: 1 O/8/24 Well iD# 65 ft. 185 ft. rock
Sa.Well Location: ft. ft. ,�` ;
Marriott ft. ft. C)1'T r 2>S
ft. ft. J
Facility/Owner Name Facility ID#(if applicable)
Phillips gap rd West Jefferson, NC ft. ft. lrf;: ,-A-.1 r'' :^y-i.:r U.P4
Physical Address,City,and Zip
ft. ft. .�.,u,
Ashe 21.REMARKS
County Parcel Identification No.(PIN)
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/tong is sufficient) 22.Certification:
36.2711 N 80.42984 Wes, 10/8/24
6.Is(are)the well(s)iPermanent or 0C Temporary Signature of Certified Well Contractor Date
By signing lids form,i hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: I Yes or EiNo 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 rnastn:clion 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:
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: 185 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdfiferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,information Processing Unit,
Ifuater 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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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) 40 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. I
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016