GW1--00442_Well Construction - GW1_20240116

• . . F-Print Form-1
WELL CONSTRUCTION RECORD(GW-Il • '.For Internal Use Only'. ' .
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1.Well Contractor Information:
Daniel urnmers . ' 14.WATER ZONES
Well Contractor Name ' FROM .' .TO . . 'DESCRIPTION . , . . . . . '
. 31 ft,. 41 ft' ' ,
• 2579-A
ft: ft.. .
NC Well Contractor Certification Number . - 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Carolina Soil_Investigations,-LLC FROM DIAMETER " ;THICKNESS • MATERIAL
. 0 ft* . 31 ft. -. 2 Hi". • 'sch 40 pvC
Company Name `tt, t �/ 16.INNER'CASING OR TUBING(geothermal closed-loop) '
2.Well Construction Permit#: V V M030.1 322/Gaston#20995 FROM. . TO ' .DIAMETER . 'THICKNESS ' ••MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) • ft•': ft. l• in: •
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3.Well Use(check well use): ft. ft in •
Water Supply Well: 17.SCREEN
FROM TO DIAMETER'. SLOT SIZE - THICKNESS. . 'MATERIAL . .
El Agricultural . •
QMunicipal/Public : '31• ft. '41 ft. 2 in. •010. sch 40 . _ pvC
•0 Geothermal(Heatirig/Cooling Supply) 'ID Residential Water Supply(single) .ft ft •
in ,'.
• . D'Industrial/Commercial 0 Residential Water Supply(shared). 18.GROUT .
Irrigation El Wells>100,000 GPD . FROM .TO .: 'MATERIAL EMPLACEMENT METHOD&AMOUNT:
- Non-Water Supply,Well: 0 ' ft:_ 5 ft• portland, mix&Pour.
Er Monitoring. ' - 0 Recovery •
'. .5.. ft, 29 ft. bentonite. tremie
•Injection Well: ft.. fr I .
•0 Aquifer Recharge ' - 0.GroundwaterRemediation-
19.SAND/GRAVEL PACK(if applicable)
ElAquifer Storage and Recovery 13 Salinity-Barrie[ • .FROM.' . .TO . - -MATERIAL. . EMPLACEMENT.METHOD
0 Aquifer Test • Q StormwaterDrainage. 29. ft. 41• fA: . 10/30'silica sand tremie
Experimental Technology . -ID Subsidence Control. - . • . ft.. ft. . .
. D Geothermal(Closed Loop) Q,Tracer , '- '20.'DRILLING LOG(attach additional sheets if necessary) '
FROM TO' • .DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
'71 Geothermal(Heating/Cooling Return) .0 Other(explain under#21 Remarks),
. 0, ft' 41: ft- brown silt loam/brown silty clay/:saprolite. '
- 4,Date Well(s)Completed:'11`20-23' _ Well ID# MW-3 ft. ft. - •
5a.WellLocation: . ' 'ft.• ft. . ' rn,.
Mountain Village Pantry ft.. . ft. = o >"
Facility/Owner Name Facility ID#(if applicable)
• ft: ft' JA N ,
2302 Dallas-Cherryville Hwy Dallas, NC ft.: tc 6 2024
Physical Address,City,and Zip •
ft ft r nut ifs Zr�.�j i��•Y � 3 K
Gaston Dtt`Z.":3
. . . . 21.REMARKS , ��+.a
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County Parcel Identification No.(PIN) .
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5b.'Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' _
(if well field,one lat/long is sufficient) ' '22.Certification: '
35:31973 N -81.21734 • w, •• •Ii: 2 :4_• 11,20-23
• 6.Is(are)the well(s):QPermanent or 0 Temporary Signature of Certified Well Contractor ' ' • Date
7.Is this a repair,to an existing well: Yes or No, .By signing this'orm,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
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.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: 1 -
• .SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 41 • (ft.)
For multiple wells list all depths fdifferent(example-3@200'and 2@l00) 24a. For All Wells:-Submit this form within-30 days of completion of well
construction.to the following: '
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10.Static water level below top of casing:. . 38. . . . (ft.) - G•
If water level is above casing,use"+^ Division, •
of Water Resources,Information Processing Unit,
8„ 1617 Mail Service Center,Raleigh;NC 27699-1617
IL-Borehole diameter: (in.) j,
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: I
I.
• 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'&Infection 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 Caroling Department of Environmental Quality-Division ofWater Resources Revised 6-6-2018. •