GW1-2022-04846_Well Construction - GW1_20220520

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cody Dobbins 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft ft
4539-B ft ft
NC Well Contractor Certification Number 15:OUTER CASING for 7!!L sed wells OR LINER if a licable
Catawba Valley Engineering &Testing FROM TO DIAMETER THICKNESS MATERIAL
0 rc 15 ft 2 ii" SCH-40 PVC
Compaq Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMLITR THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft
3.Well Use(check well use): ft ft ;n
Water Supply Well: 17.SCREEN
FROM . TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft 30 ft 2 1O 0.010 SCH-40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 15 ft iv
❑lndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 11 ft Portland Tremmie
CJMonitoring ❑Recovery ft ft
Injec ion Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a Gcahle
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERAAI. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 13 ft 30 ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soi0rock in sim etc
0 IL 15 ft tan/brown silty sand
4.Date Well(s)Completed: 9/1/2021 Well W# MW 1 15 ft 25 ft yellow/orange sandy silt with sandy zones
5a.Well Location: 25 f` 30 ft brown/red silt trans itioni q y
Former Parrish Tire Co. ft ft �,- -° a--
Facility/Owner Name Facility ID#(if applicable) ft ft 9
150 East Front Street, Statesville, NC 28677 ft ft
Physical Address,City,and Zip ft ft mo
Iredell 4744058266.000 21.REMARKS A� , ' A_ `t''`_3 '
County Parcel Identification No.(PIN) Bentonite seal T'rIolm FF 13
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) C 22.Certify lion:
N� 6� W G�2u y�
10/5/2021
6.1s(are)the well(s): CJPermanent or ❑Temporary Signature of fled Well Contractor Date
By signing this form,I hereby cert fy that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
_ - 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 (ft.) Submit this GW-1 within 30 days ofwell completion per the following:
For multiple wells list all depths ifdifferein(example-3@200'and 2@100D
18 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: ((ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifivater level is above casing,use"+"
11.Borehole diameter: 8.25 (in.) Program,
For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Auger
24c.For Water SDpply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2019

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