GW1-2023-00733_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS x 14.WATER ZONES
Well Contractor Name --��; "'� r rye;'`0 FROM TO DESCRIPTION
A - 2581 E ..e �v
fr. ft..
NC Well Contractor Certification Number Zl'n Z3
J AN 1 15.OUTER CASING for mu -cased.wells O LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETElti R THICKNESSR M1IATERIAL
rL I 1 r'!';i ft. ft. in.
Company Name vlliv ',r:„ 'i:�u`•�J^ •• '16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UiC,County,Stare,Variance,etc.) 0.0 ft. 10.0 It. 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft' 20.0 ft' 2.0 in- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It. 4.0 B' PORTLANDBENTONITE SLURRY
PflMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 8.0 ft. 20.0 fr. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. fr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain sin,etc.
0.0 fr• 1.0 ft. CONCRETE/GRAVEL
4.Date Well(s)Completed: 10/1 9/22 Well ID# MW-2 1.0 ft• 9.0 It. TAN SILTY SAND
Sa.Well Location: 9.0 ft' 14.0 ft' PWR
ACME MCCRARY 14.0 ft- 20.0 ft. ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
159 NORTH STREET ASHEBORO 27204 ft. ft.
Physical Address,City,and Zip
ft. ft.
RANDOLPH 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-4.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35e 42' 27.05" N 790 48' 55.45" W e>t;�. `- 11/04/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,/hereby certify that the well(s)was(were)construcled in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofihe ofilds record has been provided to the Lrell owner.
repair under#21 remarks section or on the back of this fbnn.
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 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: 20.0
For multiple wells list all depths Ifdiijferent(example-3@a 200'and 2 tt 100') Submit this GW-1 within 30 days of well completion per the following:
1.5 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water level is above casing use"+"
11.Borehole diameter: 6.0 (in,) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-]636
12.Well construction method: AIR
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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
j
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018