GW1-2022-10457_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ronald F. Barron -n �� S.=. 14.WATER ZONES
M77r 1',�1, n
Well Contractor Name @�•lk. �d yy' ." FROM TO DESCRIPTION
ft. ft.
2091-A NOV 1 8 2022
NC Well Contractor Certification Number _ 15.DUPER CASING for multi-cased welts OR LINER if a liable
?"
Piedmont Industrial seryiMe, a9' �s FROM ft. TO ft DIAMETERtn THICKNESS MATERIAL
Company Name
.,16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: NSA FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) '+3 rt. 7 ff 2 1 ' I Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ; 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 7 ft. 12 ft. 2 1° .010 Sh 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 rt. 5 ft. 3/8 Hentohile chips tremie
z Monitoring Recovery 0 ft. 3 ft. Concrete Poured
Injection Well:
rt. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL,PACK if applicable)
Aquifer Storage and Recovery [ISallnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 5 ft• 12 ft• #3 fiiter sand Tremie
Experimental Technology Subsidence Control
Geothermal(Closed Loop) :)Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUrock e, rain size,etc.)
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks)
0 rt. 12 ft• Tan brn silty clay
4.Date Well(s)Completed:1 1-7-22 Well ID#GP-5
5a.Well Location: ft. ft. BT CCD, 12
Wilson County Solid Waste N/A
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
2400 Hwy 42E.,Wilson 27893 ft. , ft.
Physical Address,City,and Zip ft. I ft.
Wilson N/A -21.REMARKS .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 42' 57" N 77 53' 18" W
6.Is(are)the well(s)�IX Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: f7lYes or [X 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 921 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:NIA SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12 24a. For All Wells: Submit this form within 30 days of completion of well
Forntultiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:6.75 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,:use..+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Aug er 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 Su"Dly&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