GW1-2021-01737_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Onlp:
1.Well Contractor Information:
Ronald Barron ILWATERZONES
well C.cto or Name FROM TO I DESCRIPTION
2091-A IN
n.
ft. ft.
NC Nell Contractor Certification Number 15.OUTER CASING for an creed wells OR LINER ifa linble
Piedmont Industrial Services FR011 TO UTA%IFTFR THICxNESS ]IMMAL
ft. ft.
company vane in.
16.INNER CASING OR TUBING eotherttlal elmed-lao
2.W'ell Construction Permit ft: FROM TO mAT im Tlu(KNESS MATFxtat.
Jl.t.un��he.hle arena..n.o-nc......Im"I...Dar. I/`C rwm I S"" 1i.... .I.-) 0 ft 5' H. 4 in Sch 40 PVC
3.Well Use(check well use): ft. ft.
17.SCREEN
Water Supply Well:
Forest Ire DIAMETER SLOT SIZE "r111CKNESS I eLATER1. L
Agricultural []MunicipaFPublic 5' f'' 15' f'' 4 '"' .010 SGh 40 PVC
Geothermal(Heating/Codling Supply) Residential Water Supply(s'inglel ft. ft. in.
Industrial/Commercial Residential Water Supply(aIdied) 1&GROUT
Irrleatlon FROM TO %IATERIAL EMPLACEMENT METHOD&ANIGUNT
kNon-Water Supply Well: 0 H. 3' f' Concrete M ixed&P oured,8 0#
x Monitoring QRecovcn
Injection Well —
ft ft.
Aquifer Recharge Groundwater Relnediation
I9.SAND/GRAVEL PACK if• MITI.
AgUlfer Storage and RPCOCPR �SWlnln'BBRIer FROM TO )1:\TERUL EMPLACEMFYI'MF'1'HOD
Aquifer Test EStonrnsater Drainage 3' ft' 15' ft- #2 Filter Sand Tfllnled
Hxperimental lechnoloe) Subsidence Control 1'6" f- 3' f- 3/8 Bentonite Chips I Poured
Geothermal(Closed I oop) Tracer 20.DRILLING LAG attach additional sheets ifnecme
Gcothcnnal(Iieating/Cooline Return) Other(ex lain under#21 Remarks) FRmf 10 DESCRIPTIOwcolor,hardness..oiumckn ae.ern.
D. a' See attached log
4.Date W'WUs)Completed: 1-5-2021 Well IDaMW-4
5a.W'ell Location:
J.J, Gouge & Son Oil Co. N/A
Pacila,Cone,Nome Facillts ID-(ifapplicable) ft. ft.
112 Greenwood Rd.,Spruce Pine,28777 ft ft.
Physical Address,City,and 71p it. ff
Mitchell N/A 21.REMARKS
Comm Parcel Identification No.(PIN) well set with flush meunt well easing and eeneFete pad
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifreell field,one Iat/long is sufficient 22.Certification:
35 54.9470 N 82 4.5200 \\, —>
1-8-2021
6.Is(are)the well(s)E% Permanent or Temporary Starnin e et'Cenitied well Contractor Dare
8, .'gnmg this Jura¢ l hurehr...Im. rha,the.re110/an, /'rcrrr ru.nnmm'I m...cord.....
7.Is this a repair to an existing well: E3Yes or EJNo ,,h Is.W:V 0Y 0100 ur/ -1 A'f A 0;('.OYN,, tV.11( lant...... dea u
1/d..is a repo..,fill out kn.avt vdl cwte-vuetiun i b`rrnuI.....a..d erpin'.It"....nve./ in, °°P,of1hr.r.o.rd/yo her,pnnvdrJ a,dr nr//mnnem.
repo..under-21 remarks secu...or on the back.Jon,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 I GW-I is needed. Indicate TOTAL NUMBER ofwells construction details. You map also mach additional pages ifnecessm,
drilled:N/A Sl.BNI ITTAL INSTRF('"f IONS
9.'1 otal well depth below land surface: 1 5 A) 249. For All Wells: Submit this form within 30 days of completion of well
F.r mu11,1,non /.t 11 drpon n /J/ t I camp/ I:i200 e..d 1 /not construction to the following
7n1,t1
It Static water level below top of cas mg:Dry 11
h1116 Division of Water Resources,Information Processing l-nit,
I/.'rurr 1'n'I,ahmx o..'..A.a'o t 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (in.) 24b. For Inection We11s: In addition to sending the form to the address in 24a
Auger above, also submit one cops of this form within 30 days of completion of well
12.Well construction method: construction to the following.
I ir.auger,rotary,cable-direct push etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLI'WELLS ONLY: 1636 Mail Sen'ice('enter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply& Iniection Wells: In addition to sending the form to
the addresses) 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.
Forrn(W-I North Carolina Department of lur,mo nuentol puabty-Division of W."Resources Rerrsed 2-22-2016