GW1--04066_Well Construction - GW1_20230622

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Sam Bowers 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 21.21 ft. 35.0 ft• : , light brown to brown SILT
3220-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS 1 MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) •
WM0301281 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 20 ft. 2 in. Sch 40 PVC
List all applicable well permits(i.e.County,Slate, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 ft. 35 ft. 2 in' 0.010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 16 ft• grout pour
Non-Water Supply Well:
EMonitoring ❑Recovery 16 ft. 18 ft' bentonite pour
Injection Well: ft. ft. 1 .
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 18 ft. 35 ft. #2 Sand Pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2l Remarks) 0.0 ft. 0.5 ft. topsoil
05/02/2023Well ID#MW-9 0.5 ft• 15.0 ft• red/brown SILT
4.Date Well(s)Completed: 15.0 ft• 30.0 ft. light brown SILT
5a.Well Location: 30.0 ft. 35.0 ft. brown SILT
Earl Depot 0-011960 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 't •-r , -` [ A -- `s
2733 Blacksburg Road, Earl, 28038 • ft. ' ft. ~``��`'t``-` f ' '
Physical Address,City,and Zip JUN 9. 2:r ?It L J
21.REMARKS
Cleveland 2543353334
t
County Parcel Identification No.(PIN) .n. ... 7 1 7r--,--,e-r,'Ur1K
fOJ OG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.194380 N 81 .533250 W 05/02/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form, I hereby certify that the went's)was(were)constructed in accordance
with LiA NCAC 02C.0100 or 15A NCAC OK.0200 Well Construction Standards and I/tat a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record Jim been provided to the well owner.
If this is is repair,fill out known well construction information and explain the nature ofdne
repair under g2I remarks ks section or on the back() ads form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injec/ion or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 35 _(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferen/(example-3 a 200'and 2@/00') construction to the following:
10.Static water level below top of casing: 21 .21 (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: 6" (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
Solid Stem Auger
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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013