GW1-2021-07134_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD GW 1 ( Print Fon
For Internal Use Only:
I.Well Contractor Information:
James R.Wilson
Well Contractor Name
14.WATER ZONES
FROM TO DESCRD'1tON
2404A ft.
NC Well Coahactor Certifioatfon Number tt• ft.
Wilson Well Drilling, Inc. 15.OUTER CASING for multi-caeedwells ORLINER ita llcable
FROM TO DIAMETER THICIpII SS MATERIAL
Company Name 0 n• 100 & 8.25 In. SOR21
022-0997 P10
2.Well Construction Permit#• 16•IIVNER CASING OR TUBING thermal closeddoo
10
List all applicable well construction• FROM TO DIAMETER THICKNESS MATERIAL
3.Well Use(check well use): U1C
permits(r.e. ,County,State.Variance,etc.) ft. R, is
ft. in.
Water sump Well:
17.SCREEN
AgnCullul8l 13MunicipaYPublic FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Geothermal(Heating/Coolin Supply) R' ft. ib.
8 Pp Y) Residential Water Supply(single)
Industrial/Commercial ft ft In
Residential Water Supply(shared)
hri lion 1s.GROUT
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT _
- Recovery 20--ft.- -- __- ___
IVlonitOring � Portland OreWly-a bags
Infection Well: tt• It.
Aquifer Recharge Groundwater Remediation R• R•
Aquifer Storage and Recovery Salinity Battier 19.SANDIGRAVEL PACK !t a liable
Aquifer Test FROM TO MATERW EMPLACEMENT METHOD
�Stormwater Drainage It. ft,
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheeb ti'ne
Geothermal(Hestia Coolin Retum Other(explain under#21 Remarks) FROM TO DESCRIPTION---hardn eotUrock e, a clu etc,
4.Date Well(s)Completed:7-23-2021 wen M#022-0997 0 R' 4 ft. Red Clay
4 it. 90 R' Brown Shale
So.Well Location: so ft. IN ft.
Eric&Judith Carlson ft.
fL
Facility/owngr Name Facility ID#(if applicable) t7. ft.
Saddle Ridge,Warne, NC 28909 It. O
Physical Address,City,and Zip ft. ft. U
CLAY 21.REMARKS {� ..
county Parcel Identification No.(PIN) �(1�`�Cl"
Sb.Latitude and longitude in degrees/miautes/seaonds or decimal degrees:
(ifwell field,one 1at4ong is sufl'iciem)
21).Certification:
6.Is(are)the well(s) x Permanent or Temporary ignature ofCenified well Contractor Date
By signing this form,I hereby cer4fy that the well(s)was(were)constructed in c accordane
7.Is this a repair to an existing well: ©Yes or x)No with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0100 IYeU Construction Standards and that a
Ifthis is a repair,fill out!mown well c ursftwilan information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair render#21 remarks section or on the back ofthis farm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some 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.
drilled:'
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 186 (ft.) Z4a. For All Wells: Submit thia form within 30 days of completion of well
For multiple wells list all depths ji7dig'erent(example-3Q200'and 2Qa 100)
construction to the following: i
10.Static water level below top of casing:50 (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level Is above casing,use"+' g t,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: t) (in.) 24b.For Infection Wells: in addition to sending the form to the address in 24a
12.Well construction method: Air/Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Igfection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 50 Method of test:Alf 24c.For Water Suonly&Infection Wells: In addition to sending the form to
HTH Pellets 30 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016