GW1-2021-03153_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: t
1.Well Contractor Information:
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James R.Wilson , ,,� 14.WATER ZONES ! ! i
Well Contractor Name \1p\ cl ���>, FROM & I TO � DESOUPTION i
NCWC 2404A �� F� s-loqNC Well f i
WIISon WelirDrilling, Inccation a. \�� �eO �e� IL oOs[TrERC�BIl�iG formalswTIR
DIAMUMcEaysssTewa
Company Name 0 ft' 35 ft 6.25 '- I SDR21 PVC
022-1039 16.INNER CASING OR TIIBING. eothsrmai closedaoo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable aril construction permits d.e.UIC,County,State,Variance,etc.) & In
3.Well Use(check well use): ft. ft. to.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE TRICKNESS MATERIAL
Agricultural DMunicipal/Public ft. tw in.
Geothermal(Heating/Cooling Supply) xQResidential Water Supply(she) ft. &
In dustriaUCommetcial Residential Water Supply(shared)
18.GROUT....
hri on FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 & 20 tt. Portland Gravity-3 bgas
Monitoring Recovery ft ft.
Injection Well:
Aquifer Recharge 13Groundwater Remediation
Aquifer Storage and Recovery j3Salinity Barrier FROM
SAND/GRAVEL PACK MATERIAL EMPLACBMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology 13 Subsidence Control ft. R.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets ffneceffna) 7-7
27 � Sand
Geothermal eadn Coolin Return Other(explain under#21 Remarks FROM
0 M ft• T Do Dolor haMa eoturoek etc
d Stone
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4.Date Well(s)Completed.,4-13-2021 Well ID#022-1039 27 ft- 286 ft. Granite
Sa.Well Location: ft' ft'
Rex Patterson &
Facility/Owner Name Facility ID#(if applicable) ft ft
Eagle Fork, Hayesvilie, NC 28904 % n
Physical Address,City,and Zip ft ft,
Clay 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Ifwell field,one lat/long is sufficient) 22.Certification:
N w 4-13-2021
6.Is(are)the well(s)fx Permanent or 13Temporary 1611a
of Certified well Contractor Date
By signing this form,I hereby unify that the xell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 286 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths{fdifferent(—pie-3©200'and 2@1005 construction to the following.
10.Static water level below top of casing: 110 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diamater. 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air/Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.eager,rotary,cable.direct Push,etc.)
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 30 Method of test:Air 24e.For Water SuDDIv&Injection Wells; In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Pellets Amount 30 completion of wall construction to the;county health department Of the county
where constructed.
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Forst OW-1 North Carolina Department of Environmental Quality-Division of Wator Resources Revised 2.22 2016
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