GW1-2022-08762_Well Construction - GW1_20220909

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jon Pfohl 14.WATER'ZONES
FROM TO DESCRIPTION
Well Contractor Name 39.01 ft >50 ft. Uppermgstunconfinedaquifer
3301-A
ft ft.
NC Antler
Contractor CertificationNumber 15.OUTER CASING'formulti-cased`wells OR LINER of a- -li6rble
AI Iller Env. FROM TO DIAMETER THICI4�JESS MATERIAL
ft ft. i in.
Company Name 16.INNER CASING OR 7IJBING eother al closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICLTIESS I MATERIAL
List all applicable well construction permits(i.e.UIC,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 TH ICINESS MATERIAL
Agricultural [DMunicipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R ft. in.
,._I Industrial/Commercial Residential Water Supply(shared) ',18;GROUT
_ L'ri gation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft R.
x Monitoring (Temporary) QRecovery ft ft.
Injection Well:
ft ft.
Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK if a`livable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL. EMPLACEMENT METHOD
Aquifer Test OStorrnwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20:DRILLING:LOG,.atta ch additional'sheets if necessary):'
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM TO DESCRIPTION(color.hardness,soil/rock type.gmi.sae,etc.)
0 ft 38 ft. Saprolite and layers of PWR; brown
4.Date Well(s)Completed:8/9/22 Well Ill#OW-3 38 ft 50 ft- Partially weathered rock; brown
5a.Well Location: ft ft e
Ashe Co Landfill (LCID) ft ft. „;.
Facility/Owner Name Facility ID#(if applicable)
ft ft.
739 Fred Pugh Rd Crumper, NC 28617 ft ft.
Physical Address,City,and Zip ft ft. 1i1.)P}iaF3 tD7 P0�3t L;1�ung
Ashe
21.REMARKS
County Parcel Identification No-(PIN) Temporary boring to measure water depth. Boring
abandoned on 8/10/22. Drilling performed by SAEDACCO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latAong is sufficient) 22.Certification:
36.5257159 N -8-1.368862 W ,
9/2/22
6.Is(are)the well(s) Permanent or )Temporary Signa ofC4rtified Well 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: E]Yes or )No with 15A NCAC.02C.0100 or 15A NCAC 02C.0200 Well Construction 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: 50 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple wells list all depths tf diereni(example-3(200'and 2@100) construction to the following:
10.Static water level below to of cash 39.01 ft
P °g ( ) Division of Water ater Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form-to the address in 24a
air rotary 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
i
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection}Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to' the county health department of the county
where constructed. fi
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016