GW1-2022-04844_Well Construction - GW1_20220520

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cody Dobbins 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
it ft
4539-B ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a Gcable
Catawba Valley Engineering &Testing FROM To DIAMETER THICIovEss cable)MATERIAL
0 ft 30 ft- 2 1O SCH-40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed4o4o
2.Well Construction Permit#• FROM To DIAMETER THICKNESS MATEMAL
List all applicable well construction permits(1.e.UIG County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30 ft- 45 ft' 2 0.010 SCH-40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it 30 ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non- r Supply well: 0 fL 26 fL Portland Tremmie
IlMonitoring ❑Recovery ft ft.
Injec to ft. ft. _ _ -
❑Aquifcr Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 28 ft' 45 %
❑Experimental Technology ❑Subsidence Control fL &
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal FROM TO DESCRIPTION color,hardness,saillrock a s' etc
(I-Ieating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft- 10 ft redibrown silty sand
4.Date Well(s)Completed: 11/11/2021 Well ID# MW-4 10 ft 25 ft tan and brown silty sand
5a.Well Location: 25 It' 45 ft brown and black silty sand
Former Shelby Correctional Center ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft ft
254 Kemper Road, Shelby, NC 28150 ft ft
Physical Address,City,and Zip ft ft r�L_ .
Cleveland 22252 21.REMARKS
Bentonite seal from 26'-28
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
rfwcll field,one lat/lonsufficient)
( s is 22 Certification: 1 i
`3�® �$3Z�i6 N1 `l` `{SAS W ,h 1/31/2022
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of ertified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 iVell Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ojthe ojthis record has been provided to the well owner.
repair under#21 remarks section or on lire 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 45 (B') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths rjdifferent(example-3@200'and 2@I00)
34.75 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijivater level is above casing,use"+"
f Static water level below top of casing: (f� Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
w
11.Borehole diameter, 8.25 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Auger
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department 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) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018