GW1--00565_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Matt Steele 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4548 A ft. ft. -
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. 1 .in.
Company Name 16.INNER CASING'OR TUBING(geothermal closed-loop)`
WM0A I .4 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 20 ft' 2 I in. sch 40 PVC-
List all applicable well permits(i.e.County,State,Variance,Injection,etc) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 ft. 50 ft. 2 i"' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 16 ft• Grout pour
Non-Water Supply Well:
ElMonitoring ..a't!',F.: l>t'PR 16 ft. 18 ft• Bentonite pour
Injection Well: i °•--y a. a "s "�., ft. ft.
❑Aquifer Recharge ndwater Remediation 19.SAND/GRAVEL PACK(if applicable)`
❑Aquifer Storage and Recovery 1, 1 Salinity Barrier FROM . TO MATERIAL EMPLACEMENT METHOD
❑A uifer Test • 18 ft. 50 ft. Sand
q 11,.....-- !-7,n PC"-C1215fa tiv er Drainage
❑Experimental Technology D ; Subsidence Control ft. ft.
�s C
20.DRILLING LOG(attach additional sheets if necessary) .... -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑other(explain under#21 Remarks) 0 ft. 0.5 ft. Topsoil
01/03/2023 MW 27 0.5 ft• 27 ft. Tan weathered mudstone
4.Date Well(s)Completed: Wen ID# 27 ft• 34 ft. Tan weathered/fractured mudstone
5a.Well Location: 34 ft• 46 ft. Dark grey silt
Highway Mobil 00-0-0000012512 46 ft• 50 ft Brown silt to coarse sand
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
170 Evans Rd, Thomasville, NC 27360 ft. ft. -
Physical Address,City,and Zip 21.REMARKS •' :_-
Davidson 16-331-0-000-0006
County Parcel Identification No.(PIN)
5b.Latitude and degrees:Longitude in degrees/minutes/secondsg or decimal de r'-�
(if well field,one 1at/longis sufficient) r•"' Cer Ficati
35.872186 N 80.157027 w ''� 01/08/24
Signature of Certified Well Contractor ! Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 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#21 remarks section or on the back of this form. 23.Site diagram or additional wellidetails:
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: 50 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: n/a (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: 4.5 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
air hammer 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.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 m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013