HomeMy WebLinkAboutGW1-2021-03093_Well Construction - GW1_20210622 Pant Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Wcll Contractor Information: �' �
John Salmon "14 WATER ZONES
FROM TO DIUccanrrl0N
tksltcattlrvctarName 601t• 107rL
3497-A
NC tttcl!Contractor CrniPcation Number ` t^vf(7�tit0� s Jii�q� 14 OUTER CASING for maltl-eased welt OR LINER ita Ikable
Applied Resource Mana emend' p�ut FROM TO DIAIIIMSER' 77[1cIC\rsS AIATF�iIAL
PP g iL %
Company Name
3413$ ta:INNER CASING OR r»Hnvc eothermd dasedaaa V_�-
2,Well Construction Permit N FROM TO I DIAIILTER' TIIICKIESS MATERIAL
flitaff npplic'ablr rrcPYonstr*htiaa pertnns/i.r,iffC County,ltatr,I'oriaucr,rtc J ft. f• 'iR'
3.Well Use(check well use): fL n.
147 SCREEN=
Water Supply Well: FROM To I DIASMErER I I SWT SIZE I THICKNM35 I`MATERIAL Y
Agricultural 0municipal/Public 67rL 147 rL 4 trL
Geothermal(Heating/Cooling Supply) 211csidential Water Supply(single) ft. a. [n.
IndustriaUCommeretol ❑Residential water supply(shared) 19,GROUT. '
Irri tiDn FROMTO St ATEHIAG F.HM ACLMF:\T\[fl IMOD&,\NO r\7
-non-Water-Supply well: _—._ 0 fL 60 iL._. 9entonite Tremmie
Monitoring 13Rcovm rL ft
Injection Well: fL rt.
Aquifcr Recharge ❑Groundwater Rcrneiiation
�!49iSANVIGRAVEL PACK(if amNoble
AttuiferStorage and Recovery QSalin ,Barrier FROM I TO MATERIAL EHPLACE\IE\T 11E[l[OD
Aquifer Test QStonnwatcr Drainage o rL 55 ft. #2 Pour
Experimental Technology Q subsidence Control fL rL
(1eothermal(Closed Loop) [3Troccr M DRILLING LOG tottach additional sheets lfaecissa —': 7 "
Cieothcrmal(Hearin Collin Return) Other(explain under;f21 Remarks) FROM TO DE CKIPTtox color.hartlae+s.sult,ruch e.vain sin.ern
0 FL 10 It. sand
4.Date Well(s)Completed:06/02/2021 Well IDN 1 On. 20rL orange sift and sand
5a.Well Location: 20 rL 30ft' orange silty sand
J & R Homes 30D' 40rL grey silty;sand
Facilia\'lOwner Name Faciltty Intl tif,;pplieable) 40 fL 500L grey silty sand
2762 Hoffman Rd. Jackson Springs, NC 27281 50 rL 107 fL large granular sand mix with fine sand
Pif vkal,ldtbess,City,ind Mils fL rL
Moore 00055355 zr•'sEM"RKs
Calmly Parcel Identification No.(PIN)
5b,Latitude and longitude in degreesimlautes/seconds or decimal degrees:
(if well field,owlablong is suiticient) 22.Certirteat
35 09 21.33 N 79 34 13.38 w p 6grt
6.-(s(are)the well(s)OP_ermanent or [31remporary Cent cd Well Contractor Dino
Hv si in— l. that rive wel/is)-ions(x d ere)rono vivii in ue`i,rdancr
✓<m Athu`.Hirnt, l herr 'I'J rea fi'
7.is this a repair to an existing well: E)Yes or 0No with 15A hr tC 02C_010o or/sa AY_dt_"t 2C.0200 N B Crnasrrtrettar Stmtdardf and that a
if this Is a rrin,ir,fill out known well Construction n foratatimr and eiplain dre tWlure of the coin'of tilt rrcord her hero pan/led to the cell mvnrr,
repair under id 21 remarks seeiiiin or on the lntek of rhir 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 or this page to provide additional well site details or well
construction,only 1 GW-1 is nreded. Indicate TOTAL NUMBER of%rrlls construction details. You may also attach additional pages if necessary.
diilicd: S118NIT1`1 M,INSTUVI TIONS
9.Total well depth below land surface: 107(ft•) 24a. For All wells: Submit this form Within 30 days of completion of well
Formuhipdr welts list all depths if different lerample-3 tca200'aid 2 @1001 construction to the following.
10.Static water level below fop of casing: 50(rt.) Division of water Resources,Information Processing Unit,
Ifsarer!rind is uhrnc casing,use"+" 1617,Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 7 7/8 (in.) 24b.For Infection We11s: In addition to sending the form to the address in 24a
Mud Rota above,also submit one copy of this form within 30 days of completion of«ell
12.Well construction method: Rotary construction to the fallo%ting:
lie,auger,.rotary,cable,dived push.etc-i
Division orWater Resources,Underground Injection Control Program,
FOR AV ATER SUPPLY WELLS ONLY: 1636\lail Service Center,Rnleigb,,I C 27699-1636
l
13n,l'ie1J(gym) 15 Method of tesh Air Lift lac. For Water Sunni•& Inlection Vi`ells: In addition to sending the form to
o the address(cs) above, also submit one copy of this form within 30 days of
13b Disinfection type: HTH Amount: 3/o at 10g completion of well constructions to rive county'.health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016