GW1-2023-00819_Well Construction - GW1_20230113

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Michael Coleman 7 E V_+®.D A4.WATER'ZONES" ..:
Well Contractor Name FROM TO DESCRIPTION '
2992-A JAN i 'S 2023 ft. ft. {
ft. ft. i
NC Well Contractor Certification Number r^ �f C=roc a UnA
15:OUTER'CASING'fo'r-multi cased wells OR LINER`if'a luable
Cascade Drilling '" 'v�;ot�
P-1 a `i'' FROM - TO DIAMETER THICKNESS. MATERIAL
ft. ft..
Company Name p
Per E r /` /`M M OVa I :16.INNER CASING OR TUBING: ieottiei•mal closed-loo6
2:Well Construction Permit#: A /"1f, FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,Slate,.Variance,etc.) ft. & In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS _1ATERIAL
Agricultural []Municipal/Public 0 it. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) & ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. :50 : ft. Cement Tremie Pipe
Monitoring DRecovery ft. fL
Injection Well: ft. fa
Aquifer Recharge DGroundwater Remediation
19„SAND/GRAVEL PACK ifa licable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStotmwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG`attach!Additioiial sheets if necess
Geothermal(He'ating/Cooling Return) F30ther(explain under#21 Remarks) FROM TO: DESCRIPTION color,hardness,soiUmck type.grain size,etc.
0 ft 1 ft- Red brown.fine silty sand
4.Date Well(s)Completed:6/2/2022 Well ID#SAD-08 1 ft. 2 & Gray silty fine-sand
5a.Well Location: 2 ft. 19 ft' Dark red fine sandy-Silt
Former Battery Tech 19 & 44 ft- Light brown fine to medium sand
Facility/Owner Name Facility lD#(ifapplicable) 44 ft- 50 ft Granite
305 E. US Highway 64, Lexington, N.C.. ft: ft
Physical Address,City,and Zip ft. ft.
Davidson
21.REMARKS -_
County Parcel Identification No.(PIN) This is a boring that was grouted after completion.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.Certification:
760347.39 N 1634868.10 w '
M uct, C0WM4*%1 12/20/2022
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the we//(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or EINo 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 infidrination 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-I 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
For multiple wells list all depths if different(example-3 rr 00'and 2@I00') construction to the followin P
g:.
10:Static water level below top of casing:23 (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in,24a
Sonic above,also submit one.copy of tliis 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
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13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniectiori 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.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource; Revised 2-22-2016
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