GW1--00567_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. _'.0 " ss,
FROM TO. DESCRIPTION
Well Contractor Name ft. ft.
4548 A ft. . ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap ►icable)
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) ,
WM0401489 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 28 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 28 ft. 58 ft. 2 in'; 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
PP Y) pP Y
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
r.-e FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri Irrigation i"::`"`.
g ,�..• . ,��.�4 .1 0 rt. 24 ft. Grout pour
Non-Water Supply Well:t.; Le i. ' °"''.'�"
OMonitoring .t 1017134covery 24 ft. 26 rr• Bentonite pour
Injection Well: JA1d x ,UU • ft. ft.
❑Aquifer Recharge .r^,`Qfyti9 r)a Voter Remediation 19.SAND/GRAVEL PACK(if applicable).
x-. •1 ( '•"` FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Ii t;tiVeiy Dv,i0i3C,Enalinity Barrier
26 ft. 58 ft. Sand
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary).
OGeothermal(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
4.Date Well(s)Completed: 01/02/2023`,l,ell ID#MW 28 0 5 ft. 4 ft. Brown Silt tp coarse sand
4 ft. 27 ft, Tan mudstone
5a.Well Location: 27 ft. 45 ft. Tan granite
Highway Mobil 00-0-0000012512 _-ft 50-
45 ft•
45 • Brown silt to coarse sand
Facility/Owner Name Facility ID#(if applicable) 50 ft. 58 ft. Grey granite
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 Longitude in degrees/minutes/seconds or decimal degrees: .--e :d .
(if well field,one lal/long is sufficient) g g ,?i:Ce ficati •
35.872186 N 80.157027 , � y 01/08/24
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 0Permanent or ❑Temporary 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
7.Is this a repair to an existing well: DYes or iNo copy'ofthis 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 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: 58 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following: I
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: n/a (ft.)
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
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: 1
(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
24c.For Water Supply&Injection Wells: •
13a.Yield(gpm) Method of test: 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