GW1-2021-02188_Well Construction - GW1_20210721 (3)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
14.WATERZONES
Virgil Wilson
FROM TO DESCRIPTION
Well Contractor Name 25 ft. 28 ft• Wet
4473 � fr. fr.
15.OUTER CASING for Tailti-cased wells OR LINER if a ficable
NC Well Contractor Certification Number 17, FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. `L 2021 " " in.
Company Name 1 1��; 16..INNER.CASING OR TUBING(geothermal closed-loo
CCBSIROIJ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit =410I 0 ft. 18 fr• '" sch40 pvc
Li.vi all applicable hell permits(i.e.Cmoov.Stale, W
4drtance.
ft. fL in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 18 `t' 28 ft- 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) ft ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 14 fit. Aquaguard
Non-Water Supply Well:
' 14 ft• 16 ft• Bentonite Chil Tremie
ZMonitoring ❑Recover
Injection Well: ft. rt.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK ifs Iicable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
16 30 #1!Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG-attach additional sheets if imessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sofl/mck type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. Backfill rock hole with chips
4-20-21 MW-3 28 ft. 30 ft. Sand
�.Date Well(s)Completed: Well ID#
30 ft. 41 ft. Bentonite Chips
5a.Well Location: fr. 1t.
Reids Trailer Inc ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
1410 Coltrane Mill Road, Randleman 27317
Physical Address,City,and Zip 21 REMARKS
Randolph 7748775452
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one Iat/long is sufficient)
35.911008 N -79.853458 W � 5-20-21
Sigilture ofC ell Contra Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing dvis.lbrm, l hereby ceraty that the urell(s) ivas(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been prorided to the well corner.
4 this is a repair.Jill out known uvell construction a?1brmation and explain the nature o the
repair tinder 21 renmrkv sec0on or on the hack gf1hi.,/brit. 23.Site diagram or additional well details:
You may use the back of this pageto provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-crater supply hells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 28 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
bbr undtiple hells list all depdt.s ifdifferent(example-3 n 200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.)
25 Division of Water Resources,Information Processing Unit,
1/'.rater level is above casing,use-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection 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 oflthis 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(gpm) Method of test: 24c.For Water Supply&Injection Wells:
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 G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013,