GW1-2021-02510_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 8 ft. 11 ft- non-potable water
4532-B ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER applicable)
FROM TO DIAMETER THICKNESS I MATERIAL
Excel Civil & Environmental Associates, PLLC ft. I ft. I I in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
12895 FROM I TO DIAMETER I 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.
1 Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 fL 11 f' 2 in.; 0.10 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Dndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Oh-rigation 0 ft• 2.5 ft. bentonit'e/cerr tremmie tool for cement only
Non-Water Supply Well:
ft. ft
MMonitoring Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑AquifenStorage and Recovery ❑Salinity.Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
ft• 1
❑Aquifer Test ❑Stotmwater Drainage 2.5 1 ft sand
ft. ft. -
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sell/mck ryM grain size,etc
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks 0 ft. 1 ft asphalt/gravel/clay
7-6-2021 MW-2R 2 n. rL tan silty clay
4.Date Well(s)Completed: Well ID# 8 ft. 11 ft. reddish brown sandy clay
5a.Well Location: ft. ft.
(former) Space Dye Plant ft ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
101 Main Street, McAdenville North Carolina 28101 ft rt 1
Physical Address,City,and Zip 21 REMARKS
Gaston PIN # 3585063142 0-3-ft casing
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: err ation• `J 0
(if well field,one Iattlong is sufficient)
35.261136 N -80.077218 W 8/3/2021
reed Well Con ctor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 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.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#11 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
9.Total well depth below land surface: MW2R C1 1 1' (ft.) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I001 construction to the following:
10.Static water level below top of casing: 6 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 4 (im) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in.
24a above, also submit a copy of this 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.)
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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013