GW1-2022-04845_Well Construction - GW1_20220520

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cody Dobbins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft ft
4539-B
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Catawba Valley Engineering &Testing FROM TO DL1M1IEPER THICKNEss MATERIAL
0 ft 30 ft 2 in SCH-40 PVC
Compaq Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits f.e.UIC County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
17.SCREEN
Water Supply Well:
FRO51 TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 30 ft 45 ft 2 in- 0.010 SCH-40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft 30 ft in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD, FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Ton-Water Supply Well: 0 ft 26 ft Portland Tremmie
onitoring ❑Recovery ft. ft
le ell:Aquifer Recharge ❑Groundwater Remediation19.SAND/GRAVEL PACK ifa livableAquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑StormwaterDrainage 28 ft 45 ft
❑Experimental Technology ❑Subsidence Control ft I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfmcktypp,grain sac,etc
0 ft 10 ft red/brown silty sand
4.Date Well(s)Completed: 11/11/2021 Well EN MW 5 10 ft 25 ft tan and brown silty sand
5a.Well Location: 25 ft 45 ft brown and black silty sand
Former Shelby Correctional Center ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
254 Kemper Road, Shelby, NC 28150 ft ft
Physical Address,City,and Zip ft ft
Cleveland 22252 21.REMARKS
County Parcel Identification No.(PIN)
Bentonite seal fron5
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: '-
$ w N "` ti y� i����� �a _ 1't3�'t+IQ22_�, .
Si lure o ertified Well Contractor MAY,
6.Ls(are)the well(s): InPermanent or ❑Temporary gr'a i,royi tlii�ifTaie t
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a copy
If this is a repair,fill 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.
33.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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 45 00 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3(200'and 2@100)
33.75 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifiv f Static water level below top racing: (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
rvaler level is above casing,use"+"- casing:
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
(i.e.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