WI0400560_Other_20210608

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WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Jonathan Grubbs
Well Contractor Name
3001
NC Well Contractor Certification Number
Terraquest Environmental Consultants, P.C.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
W I0400460
3. Well Use (check well use):
Water Supply Well:
Agricultural
�IGeothermal (Heating/Cooling Supply)
�I Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Municipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
�IRecovery
Injection Well:
�IAquifer Recharge
Aquifer Storage and Recovery
�IAquifer Test
�IExperimental Technology
�IGeothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 3/16/21
5a. Well Location:
Sar Express
Groundwater Remediation
J Salinity Barrier
01 Stormwater Drainage
DSubsidence Control
01 Tracer
ID Other (explain under #21 Remarks)
well ID# I NJ 1 INJ2
0-008026
Facility/Owner Name Facility ID# (if applicable)
1412 South Main Street
Physical Address, City, and Zip
Surry
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
0 ft.
ft.
in.
ft.
ft.
in.
18. GROUT
1
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
30 ft.
bentonite
pour
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft.
15 ft•
hard weathered saprolitic silt
15 ft.
25 ft.
clay
25 ft'
30 ft'
sand
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Injectant pushed through Geoprobe borings that were
backfilled with bentonite.
22. Certification:
36 29' 27.82 N 80 35' 44.07
6. Is(are) the well(s)DPermanent or XQTemporary
7. Is this a repair to an existing well: QYes or XQNo
If this is a repair, fall out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 2
9. Total well depth below land surface: 30
For multiple wells list all depths if different (example- 3@200' and 2@100)
(ft.)
10. Static water level below top of casing: ~ 15 (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 2.25 (in.)
direct push
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Signature of Certified Well Contractor
3/16/21
Date
By signing this form, I hereby cert( that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: hi addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016