GW1--04119_Well Construction - GW1_20230623

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Singleton ENvironmental, Inc. "3a.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Chris Singleton 5.93 ft 13 ft sue rs 'aawwo2
ft. ft.
NC Well Contractor Certification Number '15.OUTER CASING(for.multi-cascd'wells)OR LINER(if ap llcablc)`
3328B FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 3 ft 2 in. sch 40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) "
2.Well Construction Permit#: Var►4e- FROM TO DIAMETER THICKNESS MATERIAL '
•'i�C•
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®'Agricultural IDMunicipal/Public 3 ft 13 ft 2 in' 0.010 sch40 PVC
*Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft ft. in.
*Industrial/Commercial °Residential Water Supply(shared) 18.GROUT - '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 2 ft• Portland Pour
ES I Monitoring °Recovery ft. ft.
Injection Well:
It. ft.
'R I Aquifer Recharge °Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) -
jj11lAquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
jill1Aquifer Test QlStormwater Drainage 2.5 ft 13 ft Silica Sand Pour through hollow stem auger
*Experimental Technology ®I Subsidence Control ft. ft. .
MI Geothermal(Closed Loop) °Tracer 20.DRILLING LOC(attach additional sheets if necessary)
FROM TO DESCRII'TION(color,hardness,soil/rock type,grain size,etc.)
it Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks)
0 ft 5 ft- Brown Sandy Silt
4.Date Well(s)Completed: 5/31/2023 Well 1D#MW-1 5 ft ft. Sandy Gravel
5a.Well Location: 7 ft 12 ft Alluvium r''t t,,,, r'°''r"'S,i o S .-7-,,
Stout Property
12 ft 13 ft. .Silty Sand 3 c.'.'®i"''L..,i " 4......j r
Facility/Owner Name Facility ID#(if applicable) ft. ft J I v IN c) ? 23
20 Commerce Street ft ft I'
Physical Address,City,and Zip ft. ft lR:i:;rr«%r�N.+ F:. �a•i �i f�
CWS-O a
Brevard, NC 28712 ' :21.REMARKS._, '
Cootiri S/ t,t Ve ,. A. ' Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - -
(if well field,one 1at/long is sufficient) 22.Cer. don.
35.2409 N -82.7341 W
----- 6/14/23
6.Is(are)the well(s)JPermanent or El Temporary Signature of Certified Well Contract Date
By signing this form,I hereby cernt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or EX 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#2/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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 13 (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@1001 construction to the following:
10.Static water level below topcasing: 5.93
of g (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: 8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Hollow Stem 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: r completion of well construction toJ 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