GW1--06641_Well Construction - GW1_20241108

WELL CONSTRUCTION RECORD(OW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES.
FROM TO DESCRIPTION
Well Contractor Name
600 ft ft. 1 pint
4518-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if applicable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL
ft.
0 50 D. 6 in. PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 4040 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC.County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): R. ft. in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
II Agricultural I C Municipal/Public ft. ft. in.
NA Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft, ft. in.,
li i IndustriaUCommercial 0Residential Water Supply(shared) 18.GROUT
•[l Irrigation FROM TO , MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 22 ft• Chips Poured
jJIMonitoring JjRecovery ft. ft
Injection Well: ft. ft.
VI Aquifer Recharge II Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Ill I Aquifer Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
EliAquifer Test D[ Stormwater Drainage ft. ft.
II Experimental Technology Ell Subsidence Control ft. ft.
11'Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size.etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 fr. 40 ft• sand
4.Date Well(s)Completed: 8/29/24 Well ID# 40 ft. 805 ft. rock
5a.Well Location: ft. ft.
Moore inc ft. ft. i .`' - 'LA ;I.:.L.?
Facility/Owner Name Facility lD#(if applicable) It. ft. N I I V 0 R 2(l7d
1145 Luke st King, NC ft. ft.
ivl
ft. ft. lr.:5: -:. - ".7.--", -.r.4',,..
Physical Address,City,and Zip r: :.
Stokes 21.REIGIARKS _... ,,,._
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:
36.32524 N 80.34412 W 8/29/24
6.Is(are)the well(s)1 Permanent or ID Temporary
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EtNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fall out known well construction information and explain the nature of the copy of this record has been provided to the we!l 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: 805 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100') 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) 1 Pint 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016