GW1-2021-01736_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L Well Contractor Information:
Ronald Barron 14,WATERZONES _
P'cll Contractor Nano FROM TO UES('R I PT
ft. n.
2091-A
ft. ft.
]C R'cll Contractor Certification Number 15.OUTER CASING for mWdKxsed wells OR LINER if v linble
Piedmont Industrial Services FROM f0 UUx1EIER THICKNESS \I\TERI\L
fr. ft. m
Company Name
A I&INNER CASING OR TUBING eothermal closed-too
2.N'ell Construction Permit#: N/- - FRO\I TO In iLMXER HIM KNr:SS ILCfER111
zt„au upprcahle n.dl ra,t.tr„r,trt,t per,na,rre. uu',t'wutn.sta,e. rartattee.etr/ 0 n. g D. 4 Seh 40 PVC
3.W'ell I se(check well use): fr. ft.
Water Supply Well: 17.SCREEN
FROM 12 nrAMITER SLOTSIZE THICKNESS MATERIAL
3'
Agricultural ❑Municipal/Public f. 18' ft. 4 in .010 SCh 40 PVC
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft m
Industrial/Commercial ❑Residential Water Supple(shared) 1&GROUT
IrrlgmlOn FROM TO MATERIAL EMPLACEM ENT METHOD&AMOUNT
Son-W'aterSupply Well: 0 B. 1' If Concrete Mixed&Poured,80#
x Monitoring %❑Recover\ ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge [:)Groundwater Remediation
19.SAND/GRAVEL PACK MA applicable)
AgWfCr Storage and R2COVery ❑$ollmty barrier FROM '"12'
U ,MATERIAL EMPLACf:MnN'1'METHOD
Aquifer Pest ❑Stormwater Drainage 2' fI 18' f- #2 Filter Sand Tfifflled
Experimental Technology ❑Subsidence Control 1' fI f6 3/8 Bentonite Chips Poured
Geothermal(Closed Loop) Tracer 20.DRILLING LOG hanch additional sheets if insima
FROM TO DESCRIPTION fod.,kvttlness,s.ilhvckn te,eta.
NGeotherinal(Hcating/Coohng Return) Other(explain under#21 Remarks) B. H. See attached log
4.Date Well(s)Completed: 1-5-2021 Well lD#MW-3
n. a.
' Sa.Well Location:
J.J. Gouge & Son Oil Co. N/A ft. ft.
Faoiht}Owner Name Paeilo, In-or applicable) ft. ft.
112 Greenwood Rd.,Spruce Pine,28777 ft. ft.
Physical Address,City,and Zip I
ft. ft.
Mitchell N/A 21.REMARK$
Como, Parcel ldentiecaoct,N. (PINT well set with flush n9eunt well easing and eefieFete pad
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if.cell Geld_one IaUlong is suffic"of) 22.Certification:
35 54.9580 *1 82 4.5050 W —
/��..�1��/�� 1-8-2021
6.Is(are)the wellboEll Permanent or ❑Temporxn, Signature of(embed Well Contractor Date
B, xtgnurg Thar f rat, l horeh, cera/,i rhut rbe nrll/aJ at..n......vnuvuoed at...... rev e
7. Is this a repair to an existing well ❑Yes or Elsot , ,h/sd VT A(b1(' W00 m/ .t V u 0Zr'.0200 Wd/(.....mrermn NnaaIvr/.mud dror n
ljthts o o repair,h//nur known vr//enncvtmtion inhrrrnmum ma/ecp/um 11 nonve"I if, ,onf off]",record hag b"',pra,"I'd to of...//to,
repay under-21 remark,rrclion or nn the be,h f th,,fitrm.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page-o provide,additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnvecessary.
drilled.N/A St FINITE rAL INSTRL CTIONS
9 Total well depth below land surface: ..$ d2 H Ift) mnstru For
lo%It Weln ft)the ls:lloSub It this form within 30 days of completion of well
l- rztluplu.ell l.>all dgnha tl.h�nnr le..atnpl t�21t11 1
10.Static water level below top of casing: 14.90 (ft.) Division of Water Resources,Information Professing t nit,
11 /n•e/is oho.e fn...Le ma 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
Auger above.also submit one eop> of this form within 30 daps of completion of well
12. auell construction method: construction to the following'.
G.e.auger.rotary,cable,direct porch.etc.) `
Division of Water Resources,Inderground Injection Control Program,
FOR WATER SUPPLF WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.\'field(gam) Method of test: 24c. For Water Supply& Injection Wells: In addition to sending the torn to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the County
where constructed.
FormGW-I Nonh Carolina Depco cm of Gncimnmentalpualin-Divisionof Water Resources RevisedI-22-2016