GW1--06815_Well Construction - GW1_20241114

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 225 ft• ft, 75 gpma
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. 95 ft. 6 in. PVC
4066 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable'ell construction permits(i.e.U/C,Como;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
f Agricultural OMunicipal/Public al/Public
p it. ft. in.
[tl Geothermal(Heating/Cooling Supply) DIResidential Water Supply(single) ft. ft. in.
®i IndustriaVComnmcrcial I C Rcsidcntial Water Supply(shared)
18.GROUT
CiIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: 0 ft• 24 it' Chips Poured _
['Monitoring QRecovery ft. ft.
Injection Well:
®i Aquifer Recharge ft. ft.
Groundwater Remediation
®lAquifer Storage and Recovery C Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
ty FROM TO MATERIAL EMPLACEMENT METHOD
llg Aquifer Test .QC Stormwater Drainage ft. ft.
i/Experimental Technology DISubsidence Control ft. ft.
Ifil Geothermal(Closed Loop) C Tracer 20.DRILLING LOG(attach additional sheets if necessary)
C Geothermal(Heating/Cooling Return) ;.C Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type.grain siu,ere.)
0 ft. 85 ft. sand
4.Date Well(s)Completed: 11/1/24 Well ID# 85 ft. 265 It.
rock
ft. ft. •.. - ii
-_.-:, ' '.s , v.. :1:.,I
5a.Well Location:
Brandon Lawson ft. ft. n!Q)/ 1
2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.1065 Sechrist loop Pilot Mtn, NC ft. ft. ir,:• --: .77
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:
(dwell field,one IaUlong is sufficient) 22.Certification:
36.39919 N 80.43554 W
6..,,,_2.^ 11/1/24
6.Is(are)the well(s)> Permanent or C Temporary' Signature of Certified Well Contractor Date
By signing this fans,i hereby eerie that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: I C Yes or ONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Cnnsbnction Standards and that a
if this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner. •
repair under#21 remark,:section or on the back of this flow.
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/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: 265 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudtiple wells list all depths 11-different(example-3@200'200'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 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
12.Well construction method: Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.au er,rom construction to the following:
g ry,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 75 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.
Fonsi GW-i North Carolina Department of Environmental Quality-Division of Water Resources Reviced 7..'1-911in