GW1--00566_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. 1
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. I in.
Company Name '.16.INNER CASING OR TUBING(geothermal closed-loop) ,
WM0401489FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 25 ft 2 ' 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 25 ft' 55 ft• 2 in: 0.010 sch 40 PVC
OGeothermal(He i g/GoolingSupply�•4°11 stdential Water Supply(single) ft. ft. in.
r I, 's... ; .,, t 1s.GROUT
❑Industrial/Com ercittl„Li'L t• V k^-•4Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft.
Non-Water Supply
`N 1 S 2024 0 20 Grout pour
❑Monitoring .�r_, n,,.;„j;,,.QI g overy 21 ft• 23 ft Bentonite pour
Injection Well:kn�""'" ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 23 ft. 55 ft. Sand
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology ❑Subsidence Control
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
01/03/2023Well ID#MW-29 0.5 ft• 4 ft. • Brown silt to coarse sand
4.Date Well(s)Completed: 4 ft. 7 ft. Dark grey silt
5a.Well Location: 7 ft• 20 ft. Dark grey mudstone
Highway Mobil 00-0-0000012512 20 ft. 43 ft. Tan mudstone
Facility/Owner Name Facility ID#(if applicable) 43 ft• 46 ft. : Brown silt to coarse sand
170 Evans Rd, Thomasville, NC 27360 46 ft. 55 ft. Tan mudstone
Physical Address,City,and Zip 21.REMARKS
Davidson 16-331-0-000-0006
County Parcel Identification No.(PIN)
•
• 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: w' Crftcati
(if well field,one lat/long is sufficient)
35.872186 N 80.157027 , - 01/08/24
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ElPermanent or ❑Temporary By signing this form,I hereby certij51 that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo 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 1121 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: 55 (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100') construction to the following:
I
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 Injection 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