GW1-2021-01738_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Nell Contractor Information:
Ronald Barron 14.WATER TONES
FROM TO DESCRIPTION
ell Contracmr Halve ft ft
2091-A
R. D.
NC Well Contractor Certification Number IS.OUTER CASING for mWfi-rzvedweBa OR LINER ifa Grable
Piedmont Industrial Services FROM TO nl{f1C1 ER CKNf SS UIERIAI.
ft. ft. in.
Co,npany Name N/A
16.INNER CASING OR TUBING eothermal closed-too
2.\\¢II GbnStrnetlUn Permlf 7l: FRO>1 TO DIAMETER TIII(KRf:55 fl{rfaUl.
t.«all applloahk aeu......n,e,,anper,nnaGe. ulr,raant,.score. rar,anee,...,J Q ft. 3'6" ft. 2 ncSch40 PVC
3.Well Use(check well use): ft. I rt. in.
\\'a ter Supply Well: 17.SCREEN
FROM '10 UME'fER D SLOTSIZE l'HICKNESS MATERIAL
Agricultural Municipal/Public T15" D' 13'6" fu 2 '"' 010 Sch 40 PVC
Geothermal(Heatualcooling Supply) Residential Water Supply(su gle) ft. ft. in.
Industrial/CommemialResidential Water Supply(shared) I&GROUT
Ir1R8tlon fROM '10 MATERIAL E}1PLACEME%T METHOD&AMOUNT
Non-Water Supply Well: 0 rt. V6" ° Concrete Mixed&Poured,80#
x Monitoring �x Recocerc
Injection Well:
n.
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK( tip wble
Aquifer Storage and RCCOVBR [3Sallnuty'Bawler FROM TO MATERI:\L f:x/P1.{CF.{IEVT METHOD
Aquifer Test DStormwater Drainaae 2'6" h- 13'6" ft. #2Filfer Sand Tfllrlled
Experimental Technolo;_v Subsidence Control 1'6" ft. 2'6" ft. 3/8 Bentonde Chips I Poured
Geothermal(Closed Loop) [3TTacer 20.DRILLING IOGnaach additimulsheets ifnecessa
Geothermal(Heating/Cooling Ream) rJOber(explain under 421 Remarks) FROM TO 1DESCRIrrION aomr,n„Nnes.,oiurock t. aead
ft. f'- See attached log
4.Date wells)Completed: 1-5-2021 well IDa MW-6 ft. H.
ft. ft.
5a.well Location:
J.J. Gouge & Son Oil Co. N/A f' f'-
F.,abr,'0,ne,Name F...hisID-ofapitheable) ft' f''
112 Greenwood Rd.,Spruce Pine,28777
Physical Address,City,and Zip ft. ft.
Mitchell N/A 21.REMARKS
County Parcel ldeend,.Gon No (PIN) well set w th flush ffieuRt well easing and eeneFete pad
5b.latitude and longitude in degrees/minutes/seconds or decimal degrees:
fduell field one la/long,,sufai,icnr 22.(ertification:
35 54.9430 82 4.5110 \\.
,e�& -���.��� 1-8-2021
6.Is(are)the wellbq Permanent or E3Temporan, Signature ofCeniticd Well C mraacr Dale
HI apna,g dar/nr,n, I herah, guru/, d,m,h, "'116/ ,r n 1..er,y..,neruned u,a.ca.I.....
7.Is this a repair to an existing well: Yes or IDNo vvhh2x(:Knl('.n1onorlil VA( a]r'-o1n6iVedt'a,nvn,.sio,r Am,dwd.and din,a
If da,,a a repmr.Jill au,k,mnv..ell ennv....I r in¢vmmnn,and erplmn,hc norm.../as o pT„/,ho record hu,hren p,o,ded,o,Le,,ell o„n.r.
repair under ;21 remarks act non or on,he hack J',ho,form.
23.Site diagram or additional x'ell details:
8.For Geoprobe/DPT or Closed-Loop Geothermal W'eIIS having the same You may use the back of this page to provide additional ,cell site details or well
construction,only I GW-I is needed. Indicate'101 AL NUMBER of wells construction details- You may also attach additional pages il'necessary_
drilled N/A SE BMI'I IAL LNS'IRUCTIONS
9.Total well depth below land surface: 13�6" (ft)
P For All Wells: Submit this fom within 30 days of completion of well
For nnd»plr"e/la livr n//drprh„)dfj nm, ,/eeanrp le-3(d200'ond <2/n l ,f con r
) ? Construction to the falominC
10.Static water level below top of casing: 11.60 _ is il, (0`-� (ft) Division of Water Resources,Information Processing 1'nit,
//.n,er le.el ie aho.e casmX.u.<' 1617 Mail Service Center,Raleigh,NC 27699-1617
11. Borehole diameter: 10 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
Auger abose-also submit one copy of this turn within 30 class of completion of well
12.Well construction method: construction to the following.
lie.auger.rotary,cable,di-em ptah.en
Uivision of Water Resources,I nderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.field(grad Method of test: 24c. For Water Social, & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this Corm within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the colmly
where constructed.
Fom,G W-I Noah Carolina Depanmcnt of Envimnmenml Qua do,-Do,,c.a of Water Resources Res iced 2-22-20I6