WI0100492_Well Construction Record (GW1)_20180412 (2)

WELL CONSTRUCTION RECORD
This form ran be used for single or multiple wolfs -
1. Well Contractor Information:
David C Stratton
Well Contractor Name
3421-A 19018
NC Well Contactor Certification Number
AWD Services Inc.
Company Name
2. Well Construction Permit#: W10100492
List all applicable well construction perm/ls r.e. Comry, State, Yarmans, eta.)
3. Well Use (check well use):
❑ icultuml OMunicipal/Public
Geothermal (Heating/Cooling Supply) OResidential Water Supply (single)
❑Industrial(Commercial ❑Residential Water Supply (shared)
❑Aquifer Recharge
❑Groundwater Remediatior
OAquifer Stooge and Recovery
❑SalinityBarrier
❑Aquifer Test
❑Stormwater Drainage
❑Exper metnal Technology
OSubsidence Control
❑Geothernal(Closed Loop)
❑Tracer
4. Date Well(s) Completed: 4/02/18 WWII JD#
Sa. Well Location:
N.C. School of Science and Mathematics
Facility/Owner Name Facility 1109 (if applicable)
517 W Fleming Drive Morganton NC 28655
Physical Address, City, and Zip
Burke 2702 09 8718
County Parcel Identification No. (PM)
Sb. Latitude and Longitude in degmes/minutes/seconds or decimal degrees:
(if well field, one lit/long is sufficient) E lev. 1106
35 39' 28" J N 81 79' 56" q
6. Is (are) the weil(s): ➢Permanent or []Temporary
7. Is this a repair to an existing well: []Yes or VC
Ifthis is a repair; fill oul ibutwn well construction Information and explam The mere ofthe
repair under #21 remarks section or on the lack ofthis faun.
S. Number of wells constructed: 3
For multiple injection or non-wmersupply wells ONLY with the same construction, you con
subsell one form.
9. Total well depth below land surface: 3 @ 500' Xt.)
For multiple wells lief all deplhs lfdfferent (example- 30200' am120100')
10. Static water level below top of casing:
!-water level is above coining, use "+"
6 25
N/A
COMMERCIAL GEOTHERMAL
For Inlomal Use ONLY:
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Test Bores .e
22. Certification:
JY ,,. d (f ,,, 4/12/18
Signature of Certified Well Ci m actor Date
By signing this form, I hereby certyry that the wills) was (were) constructed in accordance
with 15A NCAC 02C .0100 ar ISA NCAC 02C.0200 Well Construction Standards and that a
copy ofthis recnrdhas been preelded to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional Well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCCIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.) Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699.1617
11. Borehole diameter: (in.) 24b. For Iniection Wells: In addition to sending the forth to the address in 24a
ratan above, also submit a copy of this form within 30 days of completion of wall
12. Well construction method: y construction to the following:
(i.e. auger, rotary, cable, direct push, eta.)
Division of Water Quality, 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 Sunnly & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form Within 30 days of
13b. Disinfection Amount: - completion of well construction to the county health department of the county
type• where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources— Division of Water Quality Revised lan. 2013