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Home My WebLink AboutGW1--00441_Well Construction - GW1_20240116 Print Form I. WELL CONSTRUCTION RECORD(GW-11 .For Internal Use Only: I ' • 1.Well Contractor Information: . ' Daniel Summers . . . . ' 14.WATER ZONES Well Contractor Name •' FROM. TO 'DESCRIPTION . . . -. 29 ft.. : 49 ft. • . • 2579-A . . . ft. ' ft.:. i . NC Well Contractor Certification Number • 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) Carolina Soil Investigations,-LLC• FROM TO.. DIAMETER THICKNESS • MATERIAL 0 ft. . .29 ft- 2 ' in. sch 40 •. pvC Company Name • 16.INNER CASING OR TUBING(geothermal closed-loop) V 2.Well Construction Permit#: V MO301322/Gaston 20995. FROM.. ' ' TO - . .DIAMETER .THICKNESS ' -MATERIAL List all applicable well construction permits(l.e.UIC,County,State;Variance,.etc.) ' : ft.•. ft. ' in. . • •3.Well Use(checkwell use): fr. fa in.•' - • Water Supply Well: . . 17.SCREEN. FROM- TO •- DIAMETER' SLOT SIZE THICKNESS MATERIAL - • D Agricultural DMunicipal/Publie ' ' : 29- ft . 49 ft . 2 " in 010 soh 40 pvC •D Geotherinal(Heatirig/Cool_ing Supply) D Residential Water Supply(single), .ft.,'' ft..' '• in.' . D'Ihdustrial/Commercial` .0 Residential Water Supply(shared) - . 18.GROUT D Irrigation- .D Wells?I00,000 GPD .. FROM .TO . .:'MATERIAL • , • EMPLACEMENT METHOD&AMOUNT: Non-Water Supply Well: ' 0 ft.. 5 ft. portland mix-&Pour Q.Monitoring .0 Recovery 5 ft- 27 ft- bentonite tremie • Injection Well:El Aquifer • ft.. ft. Aquifer Recharge. GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable) DAquifer Storage and Recovery .D Salinity Barrier .FROM. . TO . . ' -MATERIAL . •,EMFLACEMENT.METHOD . Aquifer Test 0 Stormwater Drainage - - 27 ft. 49 ft.• . 10/30 silica sand • tremie J Experimental Technology • D Subsidence Control • ft., ft. . D.Geothermal(Closed Loop) El,Tracer • 20.DRILLING LOG(attach additional sheets if necessary) ' Geothermal(Heating/Cooling Return) •D Other(explain under#21 Remarks). .FROM TO DEscRIPTIDN(color,nardaess,soil/rock type grain sae,etc.) • 0 ft..: : -49 ft. brown silt loam/brown silty clay/saprolite • 4.Date Well(s)Completed:11=20 23 . Well ID# MW-2 - - ft. - ft. - - 5a.Well Location: ft.-. • • ft.• . - Mountain Village Pantry . ft.. . ft. , . ' Facility/Owner Name . Facility ID#(ifapplicable) ft: ft a ,, y pY,"' 2302 Dallas-Cherryville Hwy -Dallas, NC ft • ft. pp . VL _7. ' 4 Physical Address,City,and Zip' • ��i lA %r}•� Ii, fo C Gaston . . 21.REMARKS Ir 'r.7. :Ci) ..,- County. - Parcel Identification No.(PIN) r�' '7" '''-'9l l i j ' 5b.Latitude and longitude.in degrees/minutes/seconds or decimal degrees: - • • (dwell field,one lat/long is sufficient) - •ZZ.Cerhhcahon: - - • ' ' :35.32003. N_ -81.21753 • W - -1 • , 11-20-23 6.Is(are)the well(s):XDPermanent or 0 Temporary Signature of Certified Well Contractor Date 7.Is this a repair to an existing well: Yes Or ElNo By-Signing this form,I hereby certify that the well(s)was(were).-constructed in accordance with ISA 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 1121 remarks section or-on the.back of this form. ' 23.Site diagram or additional well details:. 8.ForGeoprobe/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 I GW-1 is needed.Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary. drilled: 1 • ' SUBMITTAL INSTRUCTIONS . • 9.Total well depth below land surface: - 49 (ft.)- • For multiple wells list all depths if different(example-3@200'and 2@100); 24a.. For.All Wells: Submit this form within 30 days of completion of well construction to the following 10.Static water level below top Of casing: 39. .(ft.) - I ' If water level is above casing,use"1-'' Division of Water Resources,Information Processing Unit, . 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: $ - (in.) 24b:For Infection Wells: In addition to sending the form to the address in 24a 12.Well construction method: auger above,also submit one copy of.this form within 30 days of completion of well (i.e.auger,rotary,cable,direct push,etc.) - construction to the following: 1 . • 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 8&Infection Wells: In addition to sending the form to . the address(es) above,'also submit'tone copy of this•form within 30 days of ' • 13b.-Disinfection type: - Amounh' __ .-completion of well construction to:the county health department of the county where constructed. •Form GW-1 North Carolina Department of Environmental Quality-Division'ofWater Resources • Revised'6-6-2018.