GW1-2021-02680_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple ss,ells
1.Well Contractor Information:
14.WATER ZONES
D.T. CHALMERS, JR. FROM TO DESCRIPTION
Well Contractor Name ft. R.
4146A ft. n.
NC Well Contractor Certification Number IS.INNER CASING OR TUBING geothermal closed-loo
FROM TO DIAIv1ETER TFOCIINESS MATERIAL
CATLIN Engineers and Scientists 0 ft.1 70f,.1 ; 2 in.1 SCh.40 1 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER fifapplicable)
FROM TO D1.4METER THICFZ TESS MATERIAL
2.Well Construction Permit#: N/A 0 ft. 50 rL 4 in. Sch.40 PVC
List all applicable well permits(i.e.County,State, !Variance,Injection,etc.)
ft. ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 70 ft. 74.6 tr. 2 in. Slot.010 SCh.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EIa[PLACEMENT METHOD&AMOUNT
❑Irrigation 0.5It. 48 ft. Portland Cement Tremie
Non-Water Supply Well:
®Monitoring ❑Recovery ft. ft.
Injection Well: rL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a lk'able
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I To I MATERIAL PA[PLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 68 ft 75.101 Medium Sand Torpedo Sa d
❑Experimental Technology ❑Subsidence Control fL ft.
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color.hardness.soil rock type,wain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 06/10/21 Well ID#: MW-04D rt. rt. -
ft. ft. �O
5a.Well Location: �N
ft. ft.1 en
H&M Tire Services 0-018565
Facility/Owner Name Facility m#(ifapplicable) rt.
ft
232 N.Greensboro,Liberty,NC 27298 ft. rt. VJ
n�
Physical Address,City,and Zip
21.REMARKS
RANDOLPH Qt� on
County Parcel Identification No.(P[N) nJ
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lat/long is sufficient) I I
35.85521 N 79.57131 W I ( � 7/14/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): M Permanent or O Temporary By signing this form.i hereby certify that the weU(s)wets(were)constructed in accordance with
I5A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a copy of
7.Is this a repair to an existing well: O Yes or ®No this record has been provided to the well owner.
If this is a repair,ill out known well construction information and explain the nature of
the repair under T21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to 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-water supply wells ONLY with the same construction,vonu SUBMITTAL INSTRUCTIONS
can submit one form.
9.Total well depth below land surface: 75.1 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths in different(example-3 200'and 2@100) construction to the following:',
10.Static water level below top of casing: 11.6 Division of Water Resources,information Processing Unit,
lfwater level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the
address in 24a above,also submit a copy of this form within 30 days of
12.Well construction method: H.S.AUGERS/MUD ROTARY completion of well construction to the following:
(i.e.auger,rolurK cable,direct push,elc.) 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 SvaDly&Iniection Yells:
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.
13b.Disinfection type: Amount:
Adapted front Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016