GW1--00653_Well Construction - GW1_20240119

'WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: Print Form
1.Well Contractor Information: I'
NEILL PARDUE !
I 14.WATER 7.ONES j -" -
1 Contractor Name FIt0a1 TO -DESCRIPTION________
rt.. I
--
2609A 260 1it1ro I' i i..
R, .
NC\Veil Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER than Health!)AIR DRILLING INC FROM TO InAMImt THICKNESS
pl{ M.TERI,\I.
Company Name '- o ft. 66 . ft. 6. .1 I tn. PV(
396026 16.INNER CASING OR TUBING(gcdthern al closed-loop)
2.Well Construction Permit 1!: PROM _r0 _ Dimir LR THICKNESS M.\TER 1.1
List all applicable well construction permits(i.e. WC,County,Stale,Variance,cur.) ft. rt. - i--in.
6 .,
3.Wcll.Use(cheek well use): It. ft. I in.
I Water Supply\\'ell: 17.SCREEN -
I+Ium5•I 'fO DIAAIF;TER-_SLO'1'SI'/.F: TIIICI(NI�:S MATERIALS ATERIAI.Agricultural Q!Municipal/Public ft. ft. in: _
Geothermal(healing/Cooling Supply) XDResidential Water Supply(single) -'- ------•-
rr. - ft. iti.
Industrial/Commercial ❑IResidelttial Water Supply(shared)
18,GROUT
Irrigation FROM TO MATERLU. EMl'I.ACEMEN'r8ittriioU&,\JioLN_r
Non-Water Supply Well: 0 rt 20 ft. GHUU'1'!` POURED
Monitoring DRecovery ft. ft._ --_ -___--_---
In•jertion Well: _-.- I:
Ayuilia'Recharge fl. ft. ! ,
❑Cirou idsv:tict'Rentediation I
\clui,l'a'Storage and Recovery 15alinit Barrier 19.SAND/GRAVEL PACK(it'applicable)
❑ Y PROM TO NI A'I'ERL\1, EMPLACEMENT_\1 Eft toll
Aquifer Test Q Slormwaler Drainage ft. -- ft. -
•
' Iisperimental'I'echnology ©!SubsidenccCmurol It. - 1't. - -- -
•
Geothermal(Closed Loup) QDTracer • •
20.DRILLING LOG(attach ndditioim4sheets if necessary) -
Geothermal(lir,uing!Cuoliug Return) ❑Other(explain I11t1C1"/!21 Remarks) MOM _TO DESCRIPTION hailer,hardness,sniVnrctr hl,c••ruin sin.de.)
o ft. 76 It DIRT F �rn tom'�..� r +�; ,G
08 02-2023
" - .,Li
4.Date Wcll(s)Completed: Well ID!! 76 ft' 295 ft' ROCK :' '
-- ' AN
.9
' Su.Well Location: ft. ft. J1i1'� 1 LOZ�
•
• TREXLER CONSTRUSTION . . rt. --- u. j
hacility/llwuur Nameft --- fl. "-( t•Javir-`-r'1--s-s.2.''-=),„.`: 9 ifx i ... .
Facilitylllll(ifapplicable) {: , D�`Q j
1155 OAK BLUFF, SALISBURY, N.C. 28147 , ft. rt. 1,
Physical Address.City.and Zip •ft. fl. i '' -- - -
• ROWAN 458E016 . 21.REMARKS , •
County Parcel Identification No.(PIN) • i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ...."
lil'well field.one let/lung is sufficient) 22.Certif.' :,. / _ -
35` 40.096 N 80° 33.138 tv ,, l ,
' 08-02-2023
G.Is(arc)the++'cll(sI Permnnenl or ❑I'1'entpor:try Signature or Certified Well Contractor I' ' Date .
By signing this Arm, I herehe r•c•rl(fi'that;the well(s) way(were)constructed in uerordauc•e
7.Is This a repair to an existing well: [\'es or D No with ISA NC.IC'02C.0/00 or ISA NC'.IC 02C'.0:00 IVe l Construction Srandarrlc and that a
1phi.,is rr repair,fill out known well consu•uelimm iafot motion and explain the nature of the copy of Ibis record has been past a/ed tollhd well au•nei'
repair under 1121 rrmrirks.remion or on the bad o/•dtii•form. I
23.Site diagram or additional well details:,
You may use the backof this page to provide additional well sitedetails or well
S.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 OW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also!itltach additional pages necessary.
drilled:
SUBMITT'Al.INSTRUCTIONS
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nur/tiple we/6 list all depths(/'r!((/i•renl(example-3(i 200'and 2@100') construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Reso urges,Information Processing Unit,
ij+.Parr•level i.,above casing,use"r" 1617 Mail Service(enter,Raleigh,NC 27699-I617
11.Borehole diameter: 6 (in.) 24b. For Infection Wells: In additicn to sending the form to the adchnss in 24a
above, also submit one 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.)
t Division of Water Resources,Unilergrountl Injection Control Program,
FOR\\r\"1'IsR Slit{Ll'\\1?LI.S ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield()win) 15 Method of test: AIR 24c. For Water Supply Se Inlectionl Wells: It;addition to sending the form to
HTH the address(es) above, also submit One copy ofthis form within 30 clays of
13b.Disinfection type: Amount: completion of well construction tti the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources • Revised 22 201 n