GW1-2022-10458_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ronald F. Barron p r"` - r ti. � C14.WATER ZONES c
Well Contractor Name + °, n Ys FROM TO DESCRIPTION
ft. ft.
2091-A
N O V R 8 2022 ft. ' ft.
NC Well Contractor Certification Number t/� �+ ?� t 1�D4 ;45.OUTER CASING for multi ens'ed wells OR Lf n 'Iiwble
Piedmont Industrial serv�lc-e� ,-y 0 f` FROM TO DIAMETER T.M.CKNSS MATERIAL
,}a. J�.f4.y
Company Name
16'INNER CASING OR TUBING 6t6th&mzI closed-loo
2.Well Construction Permit#:N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) +3 ft• 10 fl- 2 in. Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS 'MATERIAL
Agricultural E]Municipal/Public 1.0 ft, 20 ft' 2 in. .010' Sh 40 PVC
_ Geothermal(Heating/Cooling Supply) Residential Water Supply(single) in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. 8 ft. 3/8 Bentonite chips tremie
X Monitoring Recovery 10 ft- 6 ft- .Concrete Poured
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.' AND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage 8 ft- 20 ft- #3 filter sand Tremie
Experimental Technology Subsidence Control
Geothermal(Closed Loop) DTracer "'20.DRILLING LOG attach ad'ditioniil sheets if necessa
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) I
FROM TO DESCRIPTION(color,hardness,soiUrock type, rain size,etc.
0 ft. 10 ft- Tan tlrn silty clay
4.Date Well(s)Completed:1 1-7-22 Well ID#MW-1 A 10 ft- 20 ft- grey sandy silty clay
5a.Well Location: ft. ft, BT @ 20
Wilson County Solid Waste N/A ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2400 Hwy 42E,Wilson 27893 ft. ft.
Physical Address,City,and Zip ft. ft.
Wilson N/A AL REMARKS y
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" 77 53' 18"
N W .,, 52&1 r lI-�y ZZ
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified 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: [DYes or x®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:N/A SUBMITTAL INSTRUCTIONS
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 all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:7.42 (ft,) Division of Water Resources,Information Processing Unit,
If water 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
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&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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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