GW1-2022-10452_Well Construction - GW1_20221118

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1.Well Contractor Information: §p:
Ronald F. Barron ° °- .�� ai��" -" :14.WATERZONES
Well Contractor Name 1 R® ZOZZ F ft.ROM TO DESCRIPTION
NOVIV V ft.
2091-A
NC Well Contractor Certification Number tnjj1 rurq):
J.el
15;'OUTERVASING'formulti-casedwells ORLINER`ifa' livable
Piedmont Industrial Services FROM TO DIAMETER THICKNESS MATERIAL
+3 ft. 110 ft- 2 in. Sch 40 PVC
Company Name
.�_,'
I q 16INNER CASING'ORTUBING: eotlie'�mal:closed7iio -=
2.Well Construction Permit#: I V/„ FROM TO DMAIETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc..) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
''37 SCREEN::,
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 10 ft. 20 ft- 2 in. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply shared
PP Y(shared) 18.GROUT•;::a'.;^:.:.::.:..:.. :: +.:>;:;;;::: r_�;:.;.:..::.�.:.:,.::.:.::_::::;.:;..::::::.:.:-: ::'::",..:..:•,,;:::::,...:•.:....::::,:.
Irri ation .FROM TO MATERLM EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. 8 ft, 3/8 Bentonite .Trimie
x Monitoring DRecovery 0 ft. 6 ft- Concrete Poured
Injection Well:
lAquifer
quifer Recharge Groundwater Remediation
19.,SAND/GRAVELPACK if a lienblc , :, ::.:.:................
quifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Test OStormwater Drainage 8 ft• . 20 R #1 Trimie
xperimental Technology Subsidence Control
eothermal(Closed Loop) G-Tracer 20,DRILLING LO attach additlonal sheets if necessary)
eothermal-(Heating/Cooling Return) Other'(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnen.soil/rock type,grain ah etc
0 ft. 4 ft, Orange top soil
4.Date Well(s)Completed:3-3-20 Well ID#MW-1 4 ft. 7 ft, Red, orange fat clay
5a.Well Location: 7 R' 17 ff Tan.sandy clay
Wilson Co. C&D L.F. N/A 17. ft- 20 n• Dark tan sandy clay
Facili /owner Name Facility ID# ifs livable - '-- - f�' BT 201
ty ty C applicable) — �r
2400 Hwy 42E, Wilson 27893 ft. &
Physical Address,City,and Zip ft. A.
Wilson N/A
County Parcel Identification No.(PIN) Well set W/44 Alum. Stick up Casing W/ lock, tag,
concrete. pad
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.7247432 N. -77.8644513 Wu�� 3-5-20
6.Is(are)the well(s)oPermanent or E3Temporary Signature of Certified Well'Contractor Date
By signing this form,I hereby certify that the well(s)was(Win e)constructed in accordance
7.Is this a repair to an existing well: [7Yes or E)No W11;JSA NCAC.02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
tf ills Is a repair,fill outknoivn well construction information and erplain the nature ofthe copy ofthisaecordhas been provided to the well owner.
repair under#21-remorks 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:N/A SUBMITTAL INSTRUCTIONS
00
9.Total well depth below land surface: 20. (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list ail depths IrdierenI(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:5.19 (ft) Division of Water Resources,Information Processing Unit,
If waterlevel is above casing,rise"+" 1617 Mall Service Center,Raleigh,NC 276994617
11.Borehole diameter: 10" (in.) 24b.For Injection Wells: In addition to sending the form to the addiess in 24a
Auger 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
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection.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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016