GW1-2021-02634_Well Construction - GW1_20210615

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WELL CONSTRUCTION RECORD(GW-1) ],l For Internal Use Only:
1.Well Contractor Information:
BRIAN C BAUER „,�, ;� 2021 14L WATER ZONES
Well Contractor Name Tt FROM TO DESCRIPTION
r,, �„ gC7:)�' 0 ft 20 ft. BLACK SANDY CLAY
4179-B ,;►1;3t.t n,t" >> ft. ft
NC Well Contractor Certification Number U ° 15.OUTER CASING fir�iti uxd rvele I LINER if
MOUNTAIN ENVIRONMENTAL SERVICES, INC. hROM To DIAMETER rHIcicNEss MATERIAL
0 10 ft1 2 1 SCH40 JPVC
Company Name
14 INNER CASING OR TUBING2.Well Construction Permit#:NA FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) NA fL ft. in.
3.Well Use(check well use): ft ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
Agricultural QMunicipal/Public 10 ft- 20 It- 2 'n 0.010 1 SCH40 JPVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft R io
Industrial/Commercial Residential Water Supply(shared) t&GROUT
_11rrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 2 & PORTLAND POUR
x Monitoring Recovery ft. &
Injection Well:
fL ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK
Aquifer Storage and Recovery []Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑StormwaterDrainage 5 ft 20 ft- #2 SILICA SAND POUR
Experimental Technology Subsidence Control fL ft
Geothermal(Closed Loop) Tracer 29.DRILLING LOG attack additional sheets if necessary)
Geothermal (Heating/Cooling Return) r30ther(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,wil/roch type,grain size etc
0 fL 1 ft. GRAVEL/FILL
4.Date Well(s)Completed:5/10/2021 Wetl ID#ASTMW-1 1 & 20 ft- BLACK SANDY CLAY. STRONG
5a.Well Location: ft. & PETROLEUM ODOR.
NA ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft.
EVERGREEN PACKAGING fL &
Physical Address,City,and Zip fL ft.
HAYWOO D 21•REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL FROM 2-5'.WELL DEVELOPED BY PUMPING
APPROX.15 GALLONS.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.536822 N 82.844176 W
eU�� aaU4A' 5/11/2021
6.Is(are)the well(s)oPermanent or %Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or x)No with 15A NCAC 02C.0100 or 15A NCAC 01C.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 I 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: 20 FEET (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@,200'and 1@100') construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
HSA 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 push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276"-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply At Infection 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: Amount: 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