GW1-2021-01077_Well Construction - GW1_20210303

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WELL CONSTRUCTION RECORD (GW-1) For Internal llse Only:
1.well Contractor Information:
Justin E. Nixon 14.WATER ZONES
DES
Nell Contractor Same
FROM TO
40 ft- 50 B' SanCRIPTION
d
ft.�j\
,��) '], . ft.
SC Well Contractor Certification\ m uber IS.OUTER CASING for might-cued wells OR LINER ifa liaable
Magette Well & Pump Co., Inc. FRoxl TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal Clued-too
2.N'ell Construction Permit p: FRONI 'i'O ink
SI ETER 1'{IICKNESS MATERIAL
all apPl.eahleveileansvun.„n nol•/r.('a..n, .,.are. Conan...e.el +1 p. 40 u. 4.0 SDR-17 PVC
3.Welt Ise(check well use): B. ft. t
n.
NN'ater Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERLAL
Agricultural [)Municlpal�Public 40 °' 50 D' 4 In 0.020" SCh 40 PVC
Geothermal(Heating/Coolme Supple) [)Residential'Amer Supply(single) ft n in.
Industrial/Commercial [)Residential'A ater Supply(shared) 18.GROUT
x Iffioalion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply well: 3 fL 35 f" Quik-Grout Pump thru Tremie
Monitoring Recovcrc 0 ft. 3 fL Quikrete Pouf
Injection Well:
!t. ft.
Aquifer Recharge [)Groundwater Remedlation
19.SAND/GRAVEL PACK ifa stable
Aquifer Storage and Recoven- [)Salinit% Barrier FRO'l TO MATERIAL E%e"LACENIENTM110D
Aquifer Test [)Storm ft water Drainage 35 54 It- $P#3 Trem ET
le
Experimental Technolosx [)Subsidence Control R. f.
(,eothermal(closed Loop) [)Tracer 20.DRILLING LOG attach additional sheets if neceua
DENC0.iw❑ON ucolor.hardness,mirrorkn eem.
Geothermal(Heatine/Cooline Return) Other(explain under M21 Remarks) FROM TO 0 f° 21 f° Sand
4.Date W'elbs)Completed: 27 21 Well ID# Well#3 21 R. 34 f'' Clay
Sa.Well Location: 34 f6 40 r'' Clay and Sand
Double A Farms-Paul Askew 40 f° 50 B Sand
Factors o..nerName Facdus ID,rfapplicable) 50 ft- 54 D' Clay
Foxmore Farms Rd., Hobbsville, NC 27946 ft. ft.
Phcstcal Address,Cos.and 7,p fL ft.
Gates 21.REMARKS
c Panel Idenh6cmlon No 0,1`,I 1.5 HP, 3 PH, 460V, 35 GPM, 4-inch pump set on 40 ft of
2-inch sure align pvc drop pipe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one laulong is sufficient) 22.CerY Nation:
36,353248 1176.668643
� 1-28-21
6.Islam)the well(s)OX Permanent Or [)Temporary Sian u e offenitied well Convector Dale
f3 r, tl .d 111, / u.rr . l „.clan..
7 is thisa repair to an exisnngwell [)ties or R[)NO urlll R11 ( 0100 l.a,c 410r 000 Tells r rnmA I l ndIs",a
llrh. rp 171 rk ll r a. r 7 . r /replan.the room."Id" .op. Il urd ha he,,,P nailed , tl llov,r.
repair under=2/remarks sedrn n oron the hack fl ons lnnr
23.Site diagram or additional well details:
S.For Geoprobe/DFT or Closed-Loop Geothermal N'elis hating the same You mac use the back of this page to prs nda additional well site details or well
construction-oniv I GN'-I is needed indicate TOTAL NIMBLR of wells construction details. You may also attach additional pages if necessan
drilled 1 St ENII'I IAL INSTRICTIONS
9. 1 and well depth below land surface: 50 (ft) 24a. For All Wells: Submit this form within 30 class of completion of well
Fbr arvthin,vr/ls her all d,0o ry Jo1,o n.rtsronple-3(m200'cad 2s,100') construction to the following.
10.Static water level below top ofcasing: (ft l Division of Water Resources,Information Processing/'nit,
If uorer Ir.ad o ahmr rosn.A,no,"1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.75 (in.) 24b. For Iniection N'ells: In addition to sending the form to the address in 24a
Mud Rotary above-also submit one cops of this form within 30 da%s of completion of%sell
i2.well construction method: construction to the lollowmg
„e auger_rotary.cubic dirsn push. ,, ,
Division of N'ater Resources,Inderground Injection Control Program.
FOR N:ATER St PPLY N-FEES ONLN': 1636 Mail Service Center,Raleigh,NC 27699-1636
l3a.Wield(grim) 50 Method of test:Airlift 24c. For N-ater Supply & Injection\\'ells: 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: HTH Amount: 1/2 lb completion of well construction to the county health department of the county
where constructed.
Fount G W-I North(smlmo Dc,u m scut of It o nennental Quahty-Do,sun of Water Resonrtcs Rc,,.d 222-20)6