GW1-2021-05680_Well Construction - GW1_20210727

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
James R.Wilson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2404A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for muldeased wells OR LINER it a liable
Wilson Well Drilling, Inc. FROM To DIAMETER THICKNESS MATERIAL
Company Name 0 ft 170 fL 1 6.25 in. SDR21 PVC
16.INNER CASING OR TUBING eothermalclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
[I.dusbrial/Commercial
r Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
icultural ®Municipal/Public ft. ft. in.
thermal(Heating/Cooling Supply) Residential Water Supply(single) fA In.
X®Residential Water Supply(shared) 19.GROUT
ion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL Portland Gravity-5 bags
fF- -ft.
- - - ---
Injection Well:
ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery {Salmi Barrier 19.SAND/GRAVEL PACK if a Hcable
qut g ery tY FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage fL ft.
Experimental Technology E3Subsidence Control R- ft
Geothermal(Closed Loop) Tracer 20.DRII.LING LOG attach additional sheets K necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soil/rock type,grain sire,etc.
0 fL 8 ft- Red Clay
4.Date Well(s)Completed:6-09-2021 Well ID# 8 fL 164 ft. Decomposed Rock
5a.Well Location: 104 ft. 426 ft. Granite
Jeremy Phillips ft. n.
Facility/Owner Name Facility ID#(if applicable) ft. fL
Airport Rd.Robbinsville, NC 28771 ft. fL JUL
Physical Address,City,and Zip It. ft. 41,,,,esqing U 11li
Graham 21.RENfARKS n Q ' '
uvvrllJ
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22 ertification:
N W lz� 6-09-2021
6.Is(are)the well(s)oPermanent or Temporary S' ture of Certified well Contractor Date
signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair•to en existing well: []Yes or iX No with 1 SA NCAC 02C.0100 or I SA 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:
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
filled'1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 426 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2@100) construction to the following:
10.Static water level below top of casing:40 00 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 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:
(i.e.auger,rotary,cable,direct pushy etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: Aux 24c.For Water Sunoly&Iniecltion 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 well construction ito.1 the 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
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