GW1-2021-02441_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
J. Payne Jr. 14.WATER ZONES
Billy Y FROM TO DESCRIPTION
Well Contractor Name $ ft. 10 fL non-potable water
4532-B n. rL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Excel Civil & Environmental Associates, PLLC ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
12895 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 3 fL in
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 fL 10 IL 2 in' 0.10 PVC
(Heating/Cooling PP y) PP y(single)
ft. ft. in.
❑GeothermalSupply) ❑Residential Water Supply
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 2.5 fL bentoniie/cerr tremmie tool for cement only
Non-Water Supply Well:
ft. fL
IZMonitoring ORecovery
Injection Well: tt. fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK d applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERUIL EMPLACEMENT METHOD
2.5 fL 10 fL sand
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardy soil/rack type,grain size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 fL asphalt/gravel/clay
4.Date Well(s)Completed: 7-6-2021 well ID# MW-1 R 2 ft. 6 fL tan silty clay
7 ft. 10 fL reddish brown sandy clay
5a.Well Location: ft. fL
(former) Space Dye Plant ft. ft.
Facility/Owner Name Facility ID#(if applicable) ID
ft. ft
101 Main Street, McAdenville North Carolina 28101
Physical Address,City,and Zip 21 REMARKS
Gaston PIN # 3585063142 0-3-ft casing Vp�
County Parcel Identification No.(PIN) WJ "Mcp$$
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: n: 3<�� SeG,
(if well field,one]at/long is sufficient) I `VpI I O�
35.261136 N -80.077218 W (catio 8/3/2021
rt i ified ell ntractor ' Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
10'
9.Total well depth below land surface: MW1 R @ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(different(example-3@200'and 2@I00� construction to the following:
10.Static water level below top of casing: 8' (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b.For Iniection Wells ONLY:I In addition to sending the form to the address in
24aabove, also submit a copy of1this form within 30 days of completion of well
12.Well construction method: auger construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
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 test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form'within'30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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