GW1--06640_Well Construction - GW1_20241108

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: -- - -------
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 145 ft. ft. 50 gprn
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 ft' It 6 in. PVC
3808 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: 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
l©Agricultural QMunicipal/Public ft. ft. in.
F Geothermal(Heating/Cooling Supply) DIResidential Water Supply(single) ft. ft. in.
El Industrial/Commercial i C Rcsidcntial Water Supply(shared)
18.GROUT -
i Irrigaation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 22 ft• Chips Poured
Il1Monitoring ©Recovery ft. ft.
Injection Well:
Aquifer Recharge ft. ft.
� 9 g El
®iAquifer Storage and Recovery C Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
ty FROM TO MATERIAL EMPLACEMENT' METHOD
le Aquifer Test �C Stormwater Drainage ft. ft.
II Experimental Technology D Subsidence Control ft. ft.
illi Geothermal(Closed Loop) ®!Tracer 20.DRILLING LOG(attach additional sheets if necessary)
C Geothermal(Heating/Cooling Return) I Other(explain under#2l Remarks) FROM To DESCRIPTION(color,hardness soil/rock type. nun sire,eta)
0 R- 95 B' sand
4.Date Well(s)Completed: 10/31/24 Well iD# 95 ft. 185 ft.
5a.Well Location: ft. ft. ,-,, p y o L
Cliff Butler ft. ft. 14111 t9 g 2074
Facility/Owner Name Facility lD#(it-applicable) ft. ft.
1115 Gordy rd Pinnacle, NC ft. ft.
1 r.'J
Physical Address,City,and Zip ft. ft. "' `"° '`
Stokes - 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:
36.44190 N 80.39252 w
de-" 10/31/24
IIC Temporary Signature of Certified Well Contractor Date
6.Is(are)the well(s)JPermanent or
By signing this firm,I hereby ceri/i'that the well(s)was(were)coastnhcted in accordance
7.Is this a repair to an existing well: DYes or [No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
!phis is a repair,fill out known well consinrcton 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 farm.
23.Site diagram or additional well details:
Youmay use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT 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: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths 11.different(example-3@ 200'and 2@100') 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 Mall 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:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 Method of test: sight 24c.For Water Supply&injection Wells: In addition to sending the form to
the address(es) above, also submit orie 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