GW1-2022-04478_Well Construction - GW1_20220509

F
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Virgil Wilson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 55 It. 20 ft. ' Wet
4473 ft. f.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells)OR LINER if a Gcable
FROM TO DIAMETER TNICItNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING eorhermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 3 fr. in. sch40 PVC
List all applicable well pernrtts(i.e.Coun(v,State,Variance,injection,etc.) ,
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 f` 15 fit- 2 1n., 010 SCh40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. fr. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 rr. 1 Portland Cem Tremie
Non-Water Supply Well:
0 Monitoring ❑Recovery
1 ft- 2 ft. Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO ft MATERIAL EMPLACEMENTMETHOD
❑Aquiter Test ❑Stormwater Drainage 2 ft' 15 #1 'Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG"aitach.additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,givin sae,etc.
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under#21 Remarks) 15 ft- 20 ft. Backfill with sand
4.Date Well 4-20-22 s)Completed: Well iD# MW-2 ft. ft.
ft. R.
5a.Well Location: ft. ft.
Gentry Mills, Inc. ft. fr.
Facility/Owner Name Facility ID#(ifapplicable)
2035 Kingsley Drive, Albemarle ft. ft. iutay0 9t
Physical Address,City,and Zip
21.REMARKS
Stanly 24":sonotube
County Parcel identification No.(PIN) 8"FMC
f.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 tifica ' n:
(ifwell field,one lat/long is sufficient)
35.349558 N -80.223276 W �-
Signature of Certified Well Contractor Date
6.is(are)the well(s): (OPermanent or ❑Temporary Hv signing this Jorm,/herebv ceraf i,that the welift)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCACWC.0200 Well Construction Standards and drat a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofilus record has been provided to the well ouvrer.
h"this is a repair./ill out known rre/i construction information and explain the nature q/'the
repair under-:21 remarks section or on the back q/'thi.r/brm. 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 at additional pages if necessary.
For multiple ht/ection or non-Crater suppiv rre/1s ONLY with the same construction,You can
.submit one jortn. SUBMITTAL INSTUCTiONS
9.Total well depth below land surface: 20 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/Ix list all depths i/'di#/reni(example-3 tL200'and 2 000') construction to the following:
10.Static water level below top of casing: 5 Division of Water Resources,Information Processing Unit,
q'hrater 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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: FiSA 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 Ce 4ter,Raleigh,NC 27699-1636
m Method of test: 24c.For Water Supply&Injection Wells:
13a.Yield(gp ) 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.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013