GW1--02321_Well Construction - GW1_20240410

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Alan Michael Sturchio 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4570-A 9.0 ft• 13.0 ft• Water Column
ft. ft. l
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Froehling & Robertson FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM _ TO _ DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft• 3.0 ft. 2 in. Sch.40 PVC
3.Well Use(check well use): ft. ft in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 3.0 ft• 13.0 ft• 2 in' 0.10 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 0.5 ft•. Concrete Pad
X Monitoring ❑Recovery 0.5 ft• 1.5 ft Neat Cement Placement
Injection Well:
❑Aquifer Recharge ❑Grotmdwater Remediation 1.5 ft. 2.5 ft• Bentonite Gravity
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 2.5 ft- 13.2 ft• #2 Well Gravel Gravity
❑Experimental Technology 12 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. ft.
4.Date Well(s)Completed: 3-21-21)24 Well ID# B-2A ft. ft. r.77. ,_ r_ 5--- -
5a.Well Location: ft. ft. 5 + !- :-r 'o. 1,.,,, •
..
Kerr Lake WTP ft. ft. I R 1 i��A
Facility/Owner Name Facility ID#(if applicable) ft. ft. L. T
280 Regional Water Lane, Henderson, NC 27537 ft. ft. mfOcerg:4':-.sl Pr. :;,.••.---Ii
ft. ft `.'`"
Physical Address,City,and Zip J n
Vance 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatio •
36.4338187 N -78.3544717 W
41/S/zy
6.Is(are)the well(s)JPermanent or ❑Temporary ignature of Certified Well C ntractor Date
By signing this form,I hereby certi6,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or xONo with ISA 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#21 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 Youmay 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: ' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 13.0 ft.
P ( ) 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:
10.Static water level below top of casing: 9'0 (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: 8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Auger 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.)
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&Injection 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 Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016