GW1-2022-04847_Well Construction - GW1_20220520

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cody Dobbins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft ft
4539-B ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
Catawba Valley Engineering &Testing FROM To DIAMETER TffiCKNEss MATERIAL
0 ft 18 ft 2 1O SCH-40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: EFRTO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft in.
3.Well Use(check well use): ft in.
Water Soppy Well: EN
TO DIAMETER SLOTSUM THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 33 ft 2 O 0.010 SCH-40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 18ft ;a❑lndustrial/Commercial ❑Residential Water Supply(shared) T
❑Irn ation ❑Wells>100,000 GPD TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non- er Supply Well: 0 ft 14 ft Portland Tremmie
L7Monitoring ❑Recovery ft ft
n ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 16 ft 33 ft
❑Experimental Technology ❑Subsidence Control ft It.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION tutor,hardness,soiUmcktype,grain size,etc
0 ft 15 ft tan/brown silty sand
4.Date Well(s)Completed. 9/1/2021 Well ID# M1fl/3. 15 ft 25 ft yellow/orange sandy silt with sandy zones
5a.Well Location: 25 ft 33 ft brown/reel silt transitioning to clay
Former Price's Auto Clinic ft ft �"• i;
Facility/Owner Name Facility ID#(if applicable) ft ft
128 East Front Street, Statesville, NC 28677 ft ft
MAY 0
Physical Address,City,and Zip It. It.
redell 4744056291.000 21.REMARKS
County Parcel Identification No.(PIN)
Bentonite seal from 14'-1'6�U T I iU )i i(i,2�; 0-l�til
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /L
(ifwell field,one ladlong is sufficient) 22.Cer7cation•
��t N W 0 l 4 _ 10/5/2021
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature o rtified Well Contractor Date
By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known ive/l 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 33 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple ivells list all depths ifdii ferent(example-3@200'and 2@100)
21 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifivaterleve!is above casing,use"+"
f Static water level below top of casing: 00 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
w
11.Borehole diameter: 8.25 (iH.) 24b.For ID.iection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Auger
24a For Water Supply and Open-Loon 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018