GW1-2022-03210_Well Construction - GW1_20220308

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: r
1.Well Contractor Information:
JUNIOR SETZER &14"VERiZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2853-A
ft. fL
NC Well Contractor Certification Number M5:O'UTERVASINGC fiiilimtiltl caa el=weI1910R MINER?ifls" liealile -
SETZER AND ALLAN FROM To DIAMETER THICKNESS MATERIAL
0 fp 48 ft. 1 24 in' CEMENT TILE
Company Name 4x16tTNNERYCe�S1NG;O`R�LI7BING',' eotlferiitilieloseilgd �
2.Well Construction Permit#: SW21-0546 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count)4 State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM
CREENTo DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaV1`ublic fa ft. in.
Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) fL ft. in.
Industrial/Commercial QResidential Water Supply(shared) 4P18.tGR0UT` V;� "
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 tt CEMENT 1-3/4 YARD OF CEMENT
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
?a191?SANDZ(iR"4iYEL�P,ACK?� Eh "Ueatile ' ._,. -
Aquifer Storage and Recovery Q Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer n 20 3DRILMING,VOG�diklifa"ddid6riiil/sfie tl If,iAR "ea`, .:
Geothermal eatin Conlin Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness solUrocktype, rain stye,etc.
0 tt• 48 ft- CLAY AND SAND
4.Date Well(s)Completed:2-25-2022 Well ID#
5a.Well Location:
KIMBERLY KURKENDALL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft
169 MIDDLE OAKS TRAIL
Physical Address,City,and Zip ft. ft. O
RUTHERFORD NC 28139 a:21>REtARKS �y :r'r. ,h,r: k4kr � x5 ?�§
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(if well field,one lat/long is sufficient) 22.Certification:
35.429125 N -82.098979 W 1 ! 2-25-2022
6.Is(are)the well(s)O% Permanent or 13Ternporary Si'grfature of Certufied ell 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: QYes or )No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Constnuction 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: 48 (ft•) 24a. For All Wells: Submit!this form within 30 days of completion of well
For multiple wells list all depths if dii event(example-3Q200'and 2©1001 construction to the following:
10.Static water level below top of casing: 39 (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: 24 (in.) 24b.For Iniection Wells: In'addition to sending the form to the address in 24a
AUGER 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 27699-1636
13a.Yield(gpm) 9 Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the forth to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: CHLORINE Amount: t cup completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016