GW1--06406_Well Construction - GW1_20241025

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: "7.7___. _ _ _ ‘
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 185 ft. ft. 1O gpm
fL ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER.(if an licable) -
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 164 ft' I 6 '" 1 PVC
1125 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.U/C,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
Ilia'Agricultural QMunicipal/Public ft. ft. ' in.
II!Geothermal(Hcating/Cooling Supply) DResidential Water Supply(single)
ft. ft. in. .
Et Industrial/Commercial QResidcntial Water Supply(shared) _
18.GROUT_ .
I Irrigation - FROM TO MATERIAL EMPLACEMENT METHOD Si AMOUNT
Non-Water Supply Well: 0 ft- 20 It. Chips Poured
•
1lMonitoring ©Recovery ft. ft.
injection Well:
II Aquifer ft. ft.
q RechargeC Groundwater Remediation
1� '19:.SAND/GRAVEL PACK(if applicable) -I Aquifer Storage and Recovery ip Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
IDlAquifer Test IDStonnwater Drainage ft. ft.
to Experimental Technology OSubsidence Control ft. ft.
li Geothermal(Closed Loop) OlTracer
20.DRILLING LOG(attach additional sheets if necessary)
C Geothermal(Heating/Cooling Retum) Other(explain under Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain sire,etc.)
0 ft. 54 ft. sand
4.Date Well(s)Completed: 10/21/24 Well ID# 54 ft. 225 D
rock
5a.Well Location: ft. ft. E
Richard Tomko ft. ft.
Facility/Owner Name Facility UN(if applicable) ft. ft. U 1.. I :I; to 2024
675 Billings hill church rd Traphill, NC ft. ft.
Physical Address,City.and Zip ft. ft. c_ ,-.7..
'^" o
Wilkes 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Certification:
36.33391 N 80.02066
W Carr w-t..L" - 10/21/24
6.Is(are)the well(s)OPermanent or t C Temporary Signature of Certified Well Contractor Date
By signing diis.frum.i hereby certify that the ud11(s)was(werel constructed in accordance
7.Is this a repair to an existing well: ©Yes or No with 1.5.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If thlr is a repair,fill out known well constuctlon information and explain the nature of the copy ofthis ream!has been provided to the well owner.
repair under 021 remarks section or on the back of this fornt.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPI or Closed-Loop Geothermal Wells having the same
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: 225 (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@1001
construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing
If enter level is above casing,use"+" Unit,
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) 10 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: 1 60Z completion of well construction to'the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016