GW1-2021-01741_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Ronald Barron 14.WATERZONES
well Contractor Nmnc FROM fc TO DESCRIPTION
2091-A
ft. f[.
SC Well Conrcacns Ceuification Number 15.OUTER CASING for mWti-eased welts OR LINER If &able
Piedmont Industrial Services FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Ceti Norte
IG INNER CASING OR NBING eothermal closed-loo
2.Well Construction Permit N: FROM TO DIAMETER THICKNESS MATERIAL
c,,,,au appfioanle ae//canvueN,n,pern,tr,0 UY roemro,state. ..,..tire.ete.J 0 ft. 3' ft. 4 In' Sch40 PVC
3.Well Use(check well use): ft. I ft. I
Water Supply Well: 17.SCREEN
FROM
TO DIAMETER SLUT SILT. TNICKNF.SS MAl'f:RIAI.
Agricultural ❑Mums pal/Public 3' fr. 18' f- 4 ' -010 Sch 40 PVC
Geothermal(Heating-,/Corshma Supply) [)Residential Water Supply(single) fL PL ,
n.
Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
Irri anon FROM TU )MATERIAL F.a1 PhACEMENI MEMOD&AfO11N'I'
Son-Water Supply W'ell: 0 rt. 1' rt. Concrete Mixed&Poured,80#
X Monitoring %❑Rccove,
Injection Well:
ft. ft.
Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa liable
Aquifer Storage and Recovery []Salinity Barrier FROM TO )IArF.aul. EMPLACEMENT MLTHOD
Aquifer lest ❑Stormwater Drainage 2' ft. 18' ft. #2 Filter Sand JTrirnied
Experimental'lechnology []Subsidence Control 1' ft. 1 2' f- 318 Bentonite Chips I Poured
Geothermal(Closed loop) ❑Tracer 20.DRILLING LOG attach additi ..I sheets ifueresse
FROM TO DESCRIPrIONtroloq hardness.soiVraakry u,etc.
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) ft ft
See attached log
4.Date Wells)Completed: 1 5 2021 Well IDN MW-5 ft. ft.
Sa.Well Location: ft. ft.
J.J. Gouge & Son Oil Co. N/A f. D.
Fncilip,0wner Name F,trdho-ID=(ifopphesible) ft. f.
112 Greenwood Rd.,Spruce Pine,28777 ft. ft.
Physical Address,City,and Zip ft. ft.
Mitchell N/A 21.REMARKS
Count, Parcel IdemificaEon N. (PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Mifwell field,one halos,is offlk,emI 22.Certification:
35 54.9650 82 4.5010 W
.< e- t 1-8-2021
6.Isure)the well(s)E% Permanent or ❑Temporary Signature ef(',a,ficd Well Contract., Dale
HI vgmng,his f,irn, 1 herehs r,,oli rim,,he ae///,/ tin,is,",cnne.nmmd m accor. tier
7.Is this a repair to an existing well: ❑Yes or QSo uvh li]A('Ah O7('.0100 or li4 A('.a( 02<'.0206 Wrll(lnuvncunn.Srandurd.and Chet a
(fdo,u a repair fill ow kuavn B ell e"o"i..tion... rmatian Mali"plau, he nature q1 the c,,pr of recoo'ha.,heen prarnled to oe it oamer.
re•Ixib under=21 remark,o,lion or on the back of this fours
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 ofwells construction details. You may'also attach additional pages if necessary.
drilled:WA
Zl �BCBMIT'1'AL INSTRUCTIONS9.'total well depth below land surface: 18 Xi o100 / l
24a. For Alon lo hells: Submit this form within 30 days of completion of well
h�rnuJuplc well,-li.rroil drprh.,,1/Jf ,/ pe
wing
10.Static water level below top of rasing: 15.45 (ft.) Division of Water Resources,Information Processing If
If rarer Ierel is abore ca.,,nx,e,t - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (in.) 24b. For IDiection Wells: In addition to sending the form to the address in 24a
Aug er also,e.also submit one copy of this form within 30 da}s of completion of well
12.Well construction method: construction to the following.
li c auger.rotary,cable,direct push eml
Division of Water Resources,I nderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service('enter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply & In iection Wells: In addition to sending the form to
the address(es) above, also Submit one Copy of this form within 30 days of
136.Disinfection type: Amount: completion of well construction to the county health department of the county
"here constructed.
Fenn GW-I North('amllna Department of Fm imnnrental(tuali,-Division of Water Resources Rto sed 2-22-2016