GW1-2022-03211_Well Construction - GW1_20220308

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JUNIOR S E TZ E R 4400ATER)zo1YE8 i.. .
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2853-A tt. fL j
NC Well Contractor Certification Number ('<15:OUTER CASING'.forrmultl---- ---°ORv`),s---lfEs IicatilE i �r *%
SETZER AND ALLAN FROM TO DIAMETER THICKNESS I MATERIAL.
Company Name 0 ft. 63 fL 241 In. I ICEMENT TILE
SW20-0363 9f16JRMR$C�ASING10W4Tf 3BI1!TC e0 eh mal!eli
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Valiance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt. In.
i
Q17SREENI
Water Supply Well: irE
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. rt. in.
❑Geothermal(Heating/Cooling Supply) 19Residential Water Supply(single) rt. % In.
❑Industrial/Commercial ❑Residential Water Supply(shared) -
�Pr18:l;CvRO. ;
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL CEMENT POURED CEMENT 1-3/4 YARDS
❑Monitoring ❑Recovery ft. ft.
Injection Well:
rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
n9 SAND/GR`AVEIJ0XCK(IfWppllcetile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. M
❑Geothermal(Closed Loop) ❑Tracer l'20.tDR1I T 1NGIsOG?iittii-eWiR lliiona1Yeheetr a Eiiec`ea's"a"",
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnesr soil/rock typ.e,grain size,etc.
0 ft- 63 ft. CLAY AND SAND
4.Date Well(s)Completed: 2-28-2022 Well ID# ft. ft.
a RA
5a.Well Location:
ANNA HIGGINS ft. ft. AR 2029
Facility/Owner Name Facility ID#(if applicable)
rt. ft. `
188 MEADOWS DRIVE
Physical Address,City,and Zip tt. rt." vivait Fudf j
RUTHERFORDTON NC 28139 ")Z1fRENTARtCS `t =5r .'a
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:'
(if well field,one hit/long is sufficient) 22.Certi1,1ification:
35.402908 N -82.053957 W / ' '
2/28/2022
6.Is(are)the well(s): MPermanent or ❑Temporary gn ure of Certified Wet ntractor Date
y signing this'orm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1!lNo /SA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
I'this is a repair,full out known well construction information and explain the nature of the 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 construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovice in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 63 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@a 200'and 2 a,1001
10.Static water level below top of casing: 54 (ft) Information
For All Wells: Original form to Division of Water Resources (DWR),
['water level is above casing,use '+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER 24c.For Water Su 1 and Open-Loop Geothermal Return Wells:Copy to the
ty
(i.e.auger,rotary,cable,direct push,etc.) coun environme lth ntal headepartment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) FEET Method of test:
13b.Disinfection type: CHLORINE Amount: 1-1/2 CUP
Form GW-I North Carolina Department of Environmental Quality-Division of Water Res°ources Revised 6-6-2018