GW1-2021-02188_Well Construction - GW1_20210721 (2)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Virgil Wilson 14.WATERZONES
9
_ �� FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4473 1 ,� �, 2011 ft. ft.
NC Well Contractor Certification Number L ^U�11� 15.OUTER CASING for mult%cased wells OR LINER if a licable
FROM TO DIAMETER THICICVESS MATERIAL
Parratt-Wolff, Inc. CCI"won rt• ft• in.
Company Name t D 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICk'NFSS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft. 2 i" SCh40 PVC
List all applicable well permits(i.e.Couniy,Siate. I%ariance.lnjecuon,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 f`' 15 ft 2 t"' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Su (single) R. rt. in.
P� g SPPI
Y PPIY( g )
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft. Aquaguard Tremie
Non-Water Supply Well:
OMonitoring ❑Recover\ 3 R. 4 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 rr. 15 ft- #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20..DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION itclor,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: 4-26-21 Well ID# MW-1
ft. ft.
5a.Well Location:
ft. fr.
Reids Trailer Inc
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1410 Coltrane Mill Road, Randleman 27317
rt. ft.
Physical Address,City,and Zip
21.REMARKS
Randolph 7748775452 4"Stick up
County Parcel Identification No.(PIN) 24"Sonotube
5h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22• P
fication:
(if well field.one Iatllong is sufficient)
35.911478 N -79.853143 W. �� )��t� 5-20-21
Signature o Certified Well Contractor , v
f Date
6.Is(are)the well(s): [OPermanent or ❑Temporary 8-v signing this farm, I herebv certify that the wel(s) was(mere)constructed in accordance
with 15A NCAC 0?C.0100 or I iA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this retard has been provided to the well owner.
//this is a repair.Jill out known well construction in/brmation and explain the nature q/the
repair under=21 remarks.section or on the back q/.1hi.s form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
/•ur multiple injection or non-water supply wells ONLY with the same construction,you can
submit one Jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 15 24a. For All Wells: Submit this form within 30 days of completion of well
I•br nuiltiple wells list all depdts ifdi/Jerent(example-3@200•and 2@ro0') construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
h'water level is ahove casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Injection Wells ONLY:! In addition to sending the form to the address in
8 1/4 HSA with Ott Air Hammer 24aabove, also submit a 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 push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department ofEnvironntent and Natural Resources—Division of Water Resources Revised August 201?