GW1-2021-00832_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1,Well Contractor Information:
Ronnie Stand 14,WATER TONES
FR TO OM DESCRU T105
Nell Contractor Name
2283-A rL 100 ft. 30 gpm
n. I a.
NC Well Contractor Can,ficiumn Number 15.OUTER CASING for mulfi-castd well OR LINER ifs Eubh
Grady Poole Well Company FROM TO DAv ETER THICKNESS MATERIAL.
0 n. S4 ft- 6 is .188 gait.
Compass,Name 16.INNER CASING OR TU21NG eolhermil elaaed-ho
2.Well Construction Permit k: E21-000150 FROM TO DL1!NETER THICKNESS MATERIAL
]rva]l opplimblr yell ronsrnauorr prrmns G.e. I A C'ounry..trace. I'anance.no) fL ft. in.
3.Well C'se(check sell use): ft• ft. in.
Water Supply Well: 17.SCREEN
FROM I TO I DWNIEfER SLOT SIZE THICKNESS MATERIAL
CAgncultural ❑Municipal:Public n. ft. in,
GGeothermal(Healing/Cooling Supply) OResidential Water Supply(single) ft ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) 1l.GROUT
❑lRl allow ❑Wells 1100.000 GPD FROM 70 NIATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft- 8 bgs bentonite gravity
❑Monitoring ❑Recovery R. R.
Injection Well:
rt. ft.
QAquifer Recharge ❑Ground,sater Remediation
19.SAND/GRAVELPACK ifs se)
Rubl
❑ ❑Aquifer Storage and Recovery Salmi R'Barrier FROM TOTO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnssater Drainage
ElExperimental"1'echnolog, ❑Subsidence Control ft. ft,
GGeothennal(Closed Loop) ❑Tracer 20.DRILLING LOGathch additiooA ehteb if necessa
GGeotherrnal(Heatin 'Coolm Return) UOther(eslam under 421 Remarks) mom TO DESCRIPTIONcomr,haMntaaoun k egnins&,etc.
0 ft- 2 f° topsoil
4.Date Well(s)Completed: 02/04/2021 Well IDN 2 ft- 50 ft. clay
5a.Well Location: 50 ft. 180 b- brown rock
Oscar Mena ft. ft.
Fucilip^OwnerNmne Fhcilip-ID=Ofarpbcable) ft. ft.
2319 Frazier Rd Spring Hope 27882 ft. ft.
Physical Address.City,and Zip ft. M1
Nash 274800632686 21.REMARKS
Courts Parcel Idemification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.one Iaviong is suRtcirm) 22.Certification:
" w Aeg4e4_ 2/4/2021
6.ls(are)the well(s): nPermanent or ❑Temporary Signature ofCatufied Well Contract., Data
Its sib ling this f no l hereh,rrruhvh,n the I,ell6)wa..("",I n....."d In o,,'oI.. rich
7.Is this a repair to an existing well: ❑Yes Or nND 15A.ViA( 02C-0/00 or 13.A M AC 02( 0200 Well('instruction Su caarrtr and that a copy
/f thts is a repair,fill out known well construction Information and evplam the nature of the of this rerord has keen provuted m the weR inner.
repair under e21 remarks secuen or on the hack ofthis form. - -
- 23.Site diagram or additional xell details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells haling the same r You may use the back of this page to provide additional Well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBF} I'J D wreNs 5 2�t�dd'See Over in Remarks Box).You may also attach additional pages if necessary tinted. 1 24.SUBMITTAL INSTRUCTION'S
9.Total well depth below land surface: 180 (f4)
Pm multiple we/I,lista//depths,'deferent(e,,n,I,-3r 200'an 2f?,1 lr.) _ Submit this GW-1 within 30 days of well completion per the following:
20 24a. For All Wells: Original form to Division of Water Resources (DWR),
If, Static water level below top of casing: Ift•) Information Processing Unit, 1617 MSC Raleigh,NC 27699-1617
(sorer lore/is ahn�e rusng.me
11.Borehole diameter: 6 (in,) 24b. For Injection Wells: Cop, to DWR. Underground Injection Control(IUC)
Program. 1636 MSC,Raleigh.NC 27699-1636
12.W'ell construction method: Air Rotary
24e.For Water tlllh and Open-Loop Geothermal Return Wells.Copy to the
(I e auger,rotary.cable.direct push.emJ cocountyenvironmenental health department of the counts Where installed
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing Deer 100,000 GPD: Copy to DWR,CCPCUA
List.Yield(gpm) 30 Method of test: BLOW
Permit Program, 1611 MSC.Raleigh.NC 27699-161 I
i3b.Disinfection type: HTH Amount: 1 lb.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018