GW1--05129_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
I.Well Contractor Information:
Virgil Wilson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 6 ft. 17 ft. Wet
4473 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS Al ATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TURING(geothermal closed-loop)
FROM TO DI\METER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 7 ft. 2 in. sch40 pvc
List all applicable well permits(i.e.County.State.Variance.Injection,etc.)
ft. ft. in.
3.Well Cse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 7 fl' 17 f�' 2 in. .010 sch40 pvc
ft. ft. in.
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin le)
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 1 ft 3 ft• Portland Cem Tremie
Non-Water Supply Well:
oMonitoring ❑Recover 3 ft. 5 ft• Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO NI TERIAL EMPLACEMENT NILI IOU
❑Aquifer Storage and Recovery ❑Salinity Barrier
5 ft 17 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 2o.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness, oil/rock type,train size,etc.)
OGeothermal(Heating/CoolulgReturn) ❑Other(explain under#21 Remarks) ft. ft. ^ 1 t1«
/
7-26-23 MW 11 ft. `` `� y' /
4.Date Well(s)Completed: Well ID# G
ft. ft. ink
'UG 1 R 2023
5a.Well Location: ft. ft.
Silverline Plastics ft. ft. `Or' '=^�rOCMI unit
FacilityrOwner Name Facility 1D#(if applicable) ,
1106—
ft. ft.
950 Riverside Drive, Woodfin 28804 ft. ft.
Physical Address,City.and Zip 21.REMARKS
Buncombe 973061233700000 24"sonotube with 8" FMC
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22, 'ertification•
(if well field,one lat/long is sufficient)
35.622799 N -82,579196 W t ' i` ( t\ Q• Z/L . aae
Signature of Certified Well Contractor Date
6.Is(are)the well(s): lPermanent or ❑Temporary By signing this form.I hereby certify that the wells)was(were)constructed in accordance
Rith 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
if this is a repair,fill out known well construction information and explain the nature of the
repair under#2/remarks section or on the back of this 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 injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 17 (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 a 200'and 2@100) construction to the following:
10.Static water level below top of casing 6.0 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing.use••+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 8 1/4 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
HSA+ DPT Liners 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
i re.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&Injection Wells:
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