GW1-2021-01735_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD(GW-1) For Internal Ilse Only:
1.W'ell Contractor Information:
Ronald Barron 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2091-A
n. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mdtieaaed Land OR LINER ifsi
Piedmont Industrial Services FROM TO DIAMETER THICKNESSft. ft. in.
Company Namet6.INNER CASING OR TUBING eothertmlclmed-hw2.Well Construction Permit N: FROST 1001{S/fIrER1TRIAL
Lur dl apphc'hfe veil conernamm,perms,h-n. Ul(',Crum¢'..Sma. fanmmn,... 0 fL 6g6" It- 2 in' Sch 40 PVC
3.Well Use(check well use): ft. I rc
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 6'6" rt• 16'6" ft 2 010 SCh 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in,
Industrial/Commercial ©Residential Water Supply(shared) 1&GROUT
_11trozation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 2'6" f- Concrete Mixed&Poured,80#
x Monitoring [@Recovery D. ft.
Injection Well: (t ft.
Aquifer Recharge Groundwater Remediation _
19.SAND/GRAVELPACK ifIATERIALa Iitablc
Agtllf¢r$forage and R¢COv¢R' �$ahnity Barrierer FROM TO J EMPLACEMENT METHOD
Aquifer lest �Stormv,ater Drainage 4'6" ft 16'6" ft- #2 Filter Sand Trun ed
Experimental"I-echnology Subsidence Control 2'6" It- 4'6" ft- 3/8 Benlonite Chips I Poured
Geothermal(Closed loop) 'Tracer 20.DRILLING LOG himuch additional sheeb ifnec
Geothermal(HeatmWCoohng Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION aomr,aarEneee,saWodlife,nou.ow,etc.
ft. It- See attached log
4.Date Weil(s)Completed: 1-5-2021 Well ID#MW-2 ft. ft.
Sa.W'ell Location:
. ft.
J.J. Gouge & Son Oil Co. N/A f. R.
Facility/Owner Name Facility ID_((applicable) ft. ft.
112 Greenwood Rd.,Spruce Pine,28777 ft. ft.
Physical Address,Cify,and Zip I
it. ft
Mitchell N/A 21.REMARKS
Counry Parcel Identification No.(PIN) well set with flush ffieunt well eaSiH9 ElFid eenerete pad
5b.Latitude and longitude in degrees/mintites/seconds or decimal degrees:
ofwell held,onelatllong is sufficient) 22.Certification:
35 54.9540 N 82 4.5140
<,1(-e� 11,`!3 [— 1-8-2021
6.Isolate)the well(s)EX Permanent or 13Temporary Signature ofCcnlfied Well Contractor Date
Ht srgntng rhrs I mr I herrhr ,,,,A rh.v thr ee/I(a) n r prate/c.....m r,,/to aocordunre
7.Is this a repair to an existing well: Yes or nNO u'nh/Sd AZ:-I( 112('.0/01l or tid s('d('I/X'.f1100 We/I fanorral S'rondard,and that u
IIf ern,is a repair,Jr11 am knm n veil co r r,,o,u cmoorwian and erpl'm the nature of In, ropy Jrhi.v rca'rd lms heen pronded ro rh'.ell aon,c
repmr under''-21 remark,xern'n'r an the hack of dhs f rrm.
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 atach additional pages ifnecessmA
drilled WA q St BNII FI'AL INSTRUCTIONS
�� 70G1
9 Total well depth below land surface 16 6 -' (-: X ` A) 24a, For All Wells: Submit this form within 30 days of completion of well
l= lhpfev,R,hwaildepdrsdlff 1(-amp( 36'200''arl2aa_.Im!) construction tothe following.
10 Static water level below top ofeasing: 14.65 (ft.) Division of Water Resources,Information Processing Unit,
If„u,"ho•el to'h're,song. ,,, 1617 Mail Sit,ice Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (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
0 c er construction method:auger,
Cie.auger.rotary,cable,direct push,etc.) construction to the following.
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 lest: 24a For Water Supply & Infection Wells: In addition to sending the form to
the addresses) 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 G%k-1 North Carolina Depanmern of Eavuonmental Qoalip-Division of W ater Resources Re,ised 2-22-2016