WM0401479_Well Construction Record(s) (GW-1)_20231006

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
For Internal Use
Print Form
uanlei oummers
14. WATER ZONES
Well Contractor Name
2579-A
NC Well Contractor Certification Number
Carolina Soil Investigations, LLC
FROM
TO
DESCRIPTION
15 It.
30 ft.
rt.
rt.
15. OUTER CASING for multi -cased wells OR LINER if a licable
FROM
I TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
15 ft-
2 in.
sch 40
pvc
Company Name
NCDEQ: WM0401479 / NCDOT: E092-085-23-00439
2. Well Construction Permit#:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
16. INNER CASING OR TUBING eother al closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft.
in.
ft,
in.
Water Supply Well:
0 Agricultural ❑ Municipal/Public
0 Geothermal (Heating/Cooling Supply) ❑ Residential Water Supply (single)
0 Industrial/Commercial ❑ Residential Water Supply (shared)
Irrigation ❑ Wells > 100,000 GPD
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
15 ft.
30 rt•
2 i"•
010
sch 40
pvc
tt
tt
in
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
Non -Water Supply Well:
® Monitoring 0 Recovery
0 ft.
5 ft.
portland
mix & Pour
5 ft.
13 It.
bentonite
tremie
njection Well:
Aquifer Recharge ❑ Groundwater Remediation
Aquifer Storage and Recovery ❑ Salinity Barrier
Aquifer Test ❑ Stormwater Drainage
Experimental Technology ❑ Subsidence Control
Geothermal (Closed Loop) ❑ Tracer
Geothermal (Heating/Cooling Return) ElOther (explain ( p under #21 Remarks)
ft.
ft.
19. SAND/GRAVEL PACK if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
13 ft
30 rt•
10/30 silica sand
tremie
et
ft
20. DRILLING LOG attach additional sheets if necessary)
FROM
TO
DESCRIPTION color, hardness, soil/rock type, grain size, etc.
p ft.
3 rt.
orange brown clay (moist)
4. Date We Completed: 09-14-23 Well ID# MW-2 MW-3 MW-4
5a. Well Location:
Former Bullins Grocery
Facility/Owner Name Facility ID# (ifapplicable)
1107 North Main St Walnut Cove, NC
3 ft.
30 ft.
red orange slightly sandy silt clay (moist -wet)
ft.
ft
ft.
ft.
ft.
ft.
Physical Address, City, and Zip
Stokes
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ft.
ft.
21. REMARKS
(if well field, one lautung is sufficient) 2L. er Ica on:
36.31310 N-80.13896 W f J t(,- 09-14-23
6. Is(are) the well(s):® Permanent or 0 Temporary
7. Is this a repair to an existing well: 0 Yes or ® No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 3
9. Total well depth below land surface: 3@30' (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing: 20 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: $n (in.)
12. Well construction method: _
(i.e. auger, rotary, cable, direct push, etc.)
auger
Signature of Certified Well Contractor
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
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 Sum* & 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: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018