GW1-2021-01739_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W'ell Contractor Information:
Ronald Barron 14.WATERZONES
Well Contractor Namc FROM TO DESCRIPTION
ft. ft.
2091-A
ft. ft.
F( N4 ell Contractor Certification Number 15.OUTER CASING for mWti-need wells OR LINER ifa livable
Piedmont Industrial Services FRONT 0 D METkR THICKNESS NIATERIAL
ft. Fl.
Company Namc
A 1Q INNER CASING OR TUBING eoMermal closed-too
2.W'ell Construction Permit#: N/- - FROM TO Ti ET ER THICKV ESS MATERIAL
/,r,au appfinahlc wed canern,n„.„permatx ae. u/C,Catmn,.cum_r,,r,an,<..ca:J 0 rr. 6' f- 2 Sch 40 PVC
3.Well Use(check well use): ft. H, in.
Wa ter Supply Well: 17.SCREEN
FRONT TO DIANIfTF.R SLOTSILf: THICKNESS MATERIAL
Agricultural Municipal/Public 6' f- 16' ft. 2 In .010 SCh 40 PVC
Geothermal(I leatiraWcooling$upplp) Residential Water Supply(single ft R in
Industrial/Commercial Residential Water Supply(shared l 1&GROUT
Imizatlon FRONT To MATERIAL EMPLACEMENT NIETHOD&ASIOUNT
Non-Water Supply Well: 0 ft. 2' a. Concrete Mixed&Poured,80#
X Monitoring X)Rec(,vcrs ft. ft-
Injection Well:
ft ft.
Aquifer Recharge E)Groundwa[er Revaccination
19.SAND/GRAVEL PACK(`
liable
Agnlfef Storage and RCCOVCR' �$al101(y Barrier FRONT TO NIATERI:\L EMPIACF]t f:Nl'Mf:T HOD
Aquifer'rest E]IStormNsater Drainage 4' fL 16' fL #2 Filter Sand Tfl Riled
Experimental Technology Subsidence Control 2' ft 4' fI 3/8 Bentram a Chips I Poured
Geothermal(Closed Loop) Tracer 20.DRILLING LOGatlach additional eheeb if neaco
Geolhennal(Ileatira/Cooline Return) r3Other(eYlain under 421 Remarks) FRONT TO RPSCRIPTIONmr.b h.adnsss,soiIovcktv,a.grainve,ere)
H. a. See attached log
4.Date 1Aelys)Completed: 1-5-2021 WellID#MW-7 ft.
n. D.
Sa.Well Location:
J.J. Gouge & Son Oil Co. N/A ft
Factia/Ow net Name Facila, W=tiGppbeable) ft. ft
112 Greenwood Rd.,Spruce Pine,28777 ft.
Physical Address,('it,end Zip ft. ft.
Mitchell N/A 21.REMARKS
Camry Parcel Identification No.(PIN) well set w th flush FneuRt we!' easing and eoneFete pad
%Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Gf.vell field,One Iat/long is sufficient) 22.Certification:
35 54.9520 N 82 4.5160 W
�� G� 1-8-2021
6.laurel the well(s)EX Permanent or ❑'Temporary Signamrc ofCcul6ed Well Contractor Datc
at rl¢nmR dais/nnn, I hurehr reruh'rhm d,e urllo) e + nrrrry...nvmrnd u.aemrdnurr
7.Is this a repair to an existing well: r3ives or E)No with I51.f<.0 02('.0100 or I iA.AI_V Oh 0100 Wr/I('on.rnn nou Snnm/nrd.and rhm a
If I,,,a-a repmr,fill out hnonrr„nl1 wnsmm,iun i,f r naao..and c,hnn the nonvc of1he ,n ofI,,,rerorrl ha,Gen,poo Idrd,O,Pr n-ell owner.
repair ender-2/remark..rccrion m an the hock rJthie jorna.
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 Nsell site details or well
construction,only I GW-I is needed. Indicate'101 At.NIJM13FR of wells construction details. You ma}also attach additional pages if necessary.
drilled:N/A SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 16 (ft-) 24a. For All Wells: Submit this form within 30 class of completion of Nvell
I...... le nrds ll.rt all dcprh.,/d, nav(crcample-?fc200 and 2 aroo') consuuction to the follOwina-
10,Static water level below top of casing: 15.45 1(qo 1 Division of Water Resources,Information Processing Unit,
I/wmrrlend a oh •e m oa,ing.me - G 1617 Mail Sens,ice 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 cops of this form within 30 days of completion of well
sue construction method: construction to the fol louring.
(i c augerr,,rotary,cable,direct push etc.]
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Senice Center,Raleigh,NC 27699-1636
13a.field(gland Method of test: 24e. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form v,nrn 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the count}'
where constructed.
Fora GW-I North Carolina Department of 6ovimnnnenml Qualn,-Division of Ware,Resources Revised 2-22-2016