GW1--04999_Well Construction - GW1_20240828

_WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 170
1.Well Contractor Information:
Mark King 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4400-B 10 ft. 15 ft. silty sand
ft. ft.
NC Well Contractor Certification Number 1S.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
IETFROM To DIAMETER TDI(KNESS I MATERIAL.
ft. ft. in.
Company Name
16.INNER CASING OR TURING(geothermal closed-loop)
2.Well Construction Permit#: FROM ' To Dt 5 If:[Fit TIII(-KNESS '1.4TERI AI. -
List all applicable well construction permits(i.e.UDC,County,State,Variance,etc.) 0 ft. 5 ft. 1 'n' Sch40 PVC
-
3.Well Use(check well use): ft. It, in.
Water Supply Well: 17.SCREEN
FROM TO IMAM'.I ER SLOT SIZE: 1'I11('KNESS MATERIAL
°Agricultural °Municipal/Public 5 ft. 15 ft. 1 in. 0.010 SCh40 PVC
°Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. ill.
°Industrial/Commercial °Residential Water Supply(shared) -
18.GROUT
°Irrigation FROM TO NIA I LRIAI I Ntft_N(T:NI EN I NIEr110D&:NNIHI NT
Non-Water Supply Well: 0 ft. 34 ft• concrete pour
[°Monitoring Recovery 1 ft• 3 ft• bentonite pour through augers
Injection Well:
ft. it.
0 Aquifer Recharge °Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [jStormwater Drainage 3 ft- 22 ft. #2 silica sand pour through augers
Experimental Technology J Subsidence Control ft. R.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness.soil/rork ripe.grain size,etc.)
Geothermal(Heating/Cooling Return) °Other(explain under#2l Remarks) ft. ft
See consultant's log
08/12/24 MW-7S ft. ft.
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft. 6 •-
$2.75 Crystal Cleaners ft. ft. - `• `' •
:._;,
Facility/Owner Name Facility 11)#(if applicable) ft. ft. A U G 2 8 2024
5011 Mackay Rd, Jamestown 27282 ft. ft.
' Physical Address,City,and Zip ft. ft.
Guilford 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.Certification:
36 00 56.059 N -79 53 54.345
µ� C 8/23/24
2725-A for Mark Kinq
6.Is(are)the well(s)°[ Permanent or ['Temporary ,lit Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or E3 No with 15A NCAC 02C.0100 or 15A NC'AC 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-:11 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 You may use the back of this page to provide additional well site details or well
construction,only I GW-I 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: 15 (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:
10.Static water level below top of casing:'"'10 (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:8.25 (in.) 24b. For Infection 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& Infection 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