GW1-2021-01734_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.N'elI('a ITothan Information:
Ronald Barron 14.WATER ZONES
k%ell Contraetor Name FROM TO DESCRIPTION
2091-A
%C R ell Contractor Cevlficadon]umber 15.OUTER CASING for mulb<ased wells OR LINER ih liable
Piedmont Industrial Services FROM TO DLAMETER THICKNESS NIIIMRIAL
. ft. to
Company Naive
16.INNER CASING OR Tl1RING "flaermalcl,os too
2.N ell Construction Permit N: FROM TO DUNI k:TER '1'HI(KNfSS NIAIERIAL
1.,,,all apphcanre aeun,n,m,eonnpern.a,n-e. ulr,Cm,nn,some. I a"s,_ern.) p h. 6' n. 4 in. Seh 40 PVC
3.W'ell I'se(check well use): ft. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricutlural Municipal/Public 61 D• 16' R• 4 'n 010 SCh 40 PVC
Geothermal(Heating/Coolme Supply) Residential Water Supply(single) ft. R. m
Industrial/Commercial Residential Water Supply(shared) 1&GROUT
hn9atlon FRONT TO MATERIAL EMPLACEMENT METHOD&AMO(INT
Non-water Supply Well: 0 fL 2' ft- Concrete Mixed&Poured,80#
x Monitoring lRecoven ft. ft.
Injection Well:
R. D.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if. liable
Aquifer Storage and Recovers Salinity Banner FRONI TO MA TERIAL EN EMENTMETHOD
Aquifer Test �Stormeater Drainage 4 ft. 16 fc #2 Filter Send Tflnned
Experimental Technology Subsidence Control 2' f- 1 4' fe 3/8 Bentonite Chips I Poured
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheen if neeeva
Geothennal(Heatinu/Coslai Return) MOther(explain under#21 Remarks) 'Rom oU DESCRIrnovcolo,hardness,ontiankta m,em.
ft. a. See attached log
4.Date Wells)Completed: 1-5-2021 Well ID#MW-1 ft. R.
ft. ft.
�N.N'ell IgeNtlOn:
J.J, Gouge & Son Oil Co. N/A rL
Facility-OwnerName FaCIIIrcID=(ifappliwble) ft. ft.
112 Greenwood Rd.,Spruce Pine,28777 ft. f.
Phcsicd Address.C'iry,and Zip R. ft.
Mitchell N/A 21.REMARKS
Count, Parcel Identification No (PIN) well set with flush Rgeucit well easing and eenepete pad
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lit well field,one IatAong is suffcieno 22.Certification:
35 54.9530 N 82 4.5100 W 1-8-2021
6.Is(ure)the well(s)ox Permanent Or Temporary 9 Slgnanae of Certified Well Contractor Dam
-16 � L L 8, A,l„/,,,, Ibeech, crruh'J 0,a,/I(,) an, no,o,i .l,nu
7.Is this a repair to an mstmg well: Yes or N't, w'l,h III V(d( I)](' l)llll/ v 6d V H 0_( 0206 4 11( ',n,cnun ll la,/.....,phut o
/Iflhie,r a repair,f,ll our k"oo,o'll carutn coon information and erpa in rhe,mmre oflhe u,pi uflhs remr✓h..tree„proveled,o I/...11 owner.
repair under-21 remarks,recunu or on rlie hock oftho pr n.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Nells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMRFR of,vells construction details. You may also attach additional pages if necessary.
drilled:NIA SC BMITTAI.INSTR(.'CTIONS
9. 1 otal well depth below land surface: 16 (I-) 24a. For All Wells: Submit this tionn within 30 days of completion of well
I....n,duple„c((.h,valldrplh,yd,/lere.I(...../,-3�,,,200'm,d2 a 100r) construction tothe follosing
10.Static water level below top of casing: 14.40 (ft.) Division of N'ater Resources,Information Processing Unit,
Ilnarero"I tv abo,e canny.,,,, - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (in.) 24b. For Iniccfion Wells: In addition to scndine the form to the address in 24a
Auger above-also submit one copy of this form within 30 class of completion of well
12.Well construction method: construction to the following.
0 e.sage,,rotary,cable,direct push,etc l
Division of Water Resources,IndergrounI Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test 24c. For Witter Supply & luiection Wells: In addition to sending the form to
the address(es) above, also submit one copy of th s form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
,there constructed.
Fom,GWA North Carolina Depamoem of 3rvironn,enml Quality DF,onat of Water Resources Revised2-22-2016