GW1-2021-01079_Well Construction - GW1_20210303

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WELL CONSTRUCTION RECORD fGW-1) For Internal Use Onls:
1.Well Contractor Information:
Justin E. Nixon 14.WATER ZONES
well(correct.,Name �� FRONT TO DESCRIPTION
a 4265-A 50 60 1e Sand
��
X well Contractor('emncalion Somber IS.OUTER CASING for mnldeased wells OR LINER A• livable
Magette Well & Pump Co., Inc. FROM TO DI{)IETER THI(KNESS UTERI.4L
rt. ft.
Company tiame m
Ib.INNER CASING OR TL:BING eoMermd rimed-too
2.\\'ell Construction Permit 4: Fault TO DIAMETER TIH('KNE55I NIATERLAL
r,..Wlappneableaeu.,,,,..rnr....n .,.e lzr--r,,,,nn.Smm-rar....r, 1e1 +1 f- 50 D• 4.0 in SDR-17 PVC
3.W'ell Ise(check well use): ft. ft. in.
\\rater Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
.Agricultural DMunicipal'Public 50 f'' 60 ft' 4 in. 0.020" SCh 40 PVC
Geothermal(Heating'Cooling Supph') Residential APater Supply(single) ft. ft. in.
Industrial/Commercial OResidenuid Water Supph'(shared, 19.GROIT
R irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
von-W*ter Supply Well: 3 1L 37 fL Quik-Grout Pump thru Tremie
Monitoring 01trecoserc 0 1- 3 f. QUlkrete Pour
Injection Well:
ft. ft.
Aqu Recharge DGroundwater Remed)ation
19. MA/GRAVEL PACK icable
Aquifer Storage and Recovery DSabmt{Rarner FRONT TO MATERIAL EMPLACEMENT METHOD
Aquiter Test DStormwater Drainage 37 ft. 64 1L SP#3 ITremie
Fxperimenlal'lechnologp DSubsidence Control ft. I ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG Donach additional slial if lacm,
DESCRIPTION kolor.hardness.soirrorEn sue.etc.
Geothermal(IleatlneiConing Return)
TO
Other(explain under#21 Remarks l 0 f- 31 f- Sand
A.Date Well(s)Completed:2 1 21 Well ID# Well#4 31 ft. 34 ft. Clay
5a.\\'ell Location: 34 rL 50 O' Clay and Sand
Double A Farms - Paul Askew 50 IT. 60 ft. Sand
Facdnc Cosac,Same Facam lD=l ifapplmable) 60 1e 64 O' Clay
Foxmore Farms Rd., Hobbsville, NC 27946 ft. ft.
Physical Address,('ity.and Zip ft. ft.
Gates 21.REMARKS
conaa Parcel ldenndcamn Ao tPI V 1.5 HP, 3 PH, 460V, 35 GPM, 4-Inch pump set on 50 ft of
2-inch sure align pvc drop pipe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lifwell field.one lac lone is sutfiaenn 22.Cert' net ion:
36.3537133 76.6681790
" " £-�r-- 2-2-21
6.Is(are)the well(s)OPermanent or DTemporan
sEn n e af(-enmed wen(-ontmcmr Dme
H v,Ynu,g,h„ I„r ,. 1 hereh, zit that,h, if",,. --1....ved.. ,.rdnn.e
7.Is this a repair to an existing well: Ol es or ON'o on 1 i4 V,-:I,'Ila,' 11101,„r 1st%,_1, u]r/121,0 a,11. ..... nun ciandanb e,d.hm or
lllth,s,aarepay,fill aorknuunu.it awsrucunn,njrv,nooaa a.W erplem rim native n/,he ,,, 9dn.re.and has h,n prov,Jrdn,da,yellav eor
,caw.mder"21 remnrkv mno,a ar on the hack Id.../)vm.
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-onlc_ I GW-I Is needed. Indicate TOTAL NUMBER ofssells construction details. You may also attach additional pages ifnecessarc.
drilled.I St B\ITT,rAL INSTRUCTIONS
9.Total well depth below land surface: 60 (ft.) 24a. For All Wells: Submit this form within 30 class of completion of well
I....non,ple,.ell,l"l all d"'i"q d,perem/esa.nple-i(,200'and 2sr 100') construction to the following.
10.Static water level below top creasing: 9 (ft.) Division of Water Resources,Information Processing Unit,
In...r,,l"e)"ah„re n, - 1617)tail Serx ice Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.75 (in.) 24. For Iniection Wells: In addition to sendme the form to the address in 24a
Mud Rotary above, also submit one cope of this form within 30 class of completion of well
12.N'ell construction method: construction to the following.
I,e.auger.rotary_cable-d,roct push.eta.)
Dhision of Water Resources,I-nderground Injection Control Program,
FOR WATER SUPPIA W'F.LLS ONLI': 1636 Mail Senice Center.Raleigh,NC 27699-1636
13a.field(gpm) 50 Method of test:Airlift 24c. For Water Sunni' & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one cop)' of this form within 30 days of
13b.Disinfection type: HTH Amount: 1/2 lb completion of well construction to the county health department of the county
where constructed.
Form G W-I Sonh Caroliw Depamnem of I--:mironmenial Qualit.-Ui.rsion of W arer Resou¢es Revised 2-22-2016