GW1--06835_Well Construction - GW1_20241115

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Cameron Bazin 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
285 ft, ft. 5 gpm
4518-A
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
0 ft' 30 ft• 6 in. PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 020740 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County.State.Variance,etc.) ft. ft. n.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
U Agricultural ©Municipal/Public ft. ft. in.
II Geothermal(Heating/Cooling Supply) ERcsidential Water Supply(single) R. _ . ft. (n.
NIiIndustrial/Commercial IRcsidential Water Supply(shared) 18.GROUT
•
C i Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 22 ft' Chips Poured
®Monitoring ©Recovery ft. ft.
Injection Well:
ft. ft.
UtAquifer Recharge i©Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
El Aquifer Storage and Recovery C Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Ill Aquifer Test i C Stormwater Drainage ft. ft.
Si Experimental Technology Eli Subsidence Control ft. ft.
111 Geothermal(Closed Loop) L C Tracer 20.DRiLLiNG LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,sail/rack type.grain size,etc.)
lil Geothermal(Heating/Cooling Return) MOther(explain under#2I Remarks)
0 ft. 15 ft. sand
4.Date Well(s)Completed: 11/7/24 Well ID# 15 ft. 325 ft' rock
5a.Well Location: ft. ft.
Jerry Bryant R. ft.
Facility/Owner Name Facility lOS(if applicable) ft. ft. NOV 1 ,1 20
4107 little mtn rd Jonesville, NC ft. ft. U"
Physical Address,City,and Zip ft. ft.
Yadkin 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wen field,one lat/long is sufficient) 22.Certification:
36.19816 N 80.78968 N,
6, _ 11/7/24
6.Is(are)the well(s)jPermanent or OC Temporary Signature of Certified Well Contractor Date
By signing this foam,I hereby certif that the well(s)was(were)cotswnucted in accordance
7.Is this a repair to an existing well: JJYes or EINo tritl,15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction 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 tinder#21 remarks section or on the hack of this form.
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: 325 (ft-) 24a. For All Wells: Submit this farm within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 tt 100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If muter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For iniection 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) 5 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: 16OZ completion of well construction to the county health department of the county
where constructed. 1
Fort GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016