GW1-2022-08763_Well Construction - GW1_20220909

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jon Pfohl WATERZONES '
FROM TO DESCRIPTION
Well Contractor Name
3301-A 10.75 ft- >55 ft. Uppermost unconfined aquifer
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NC Well Contractor Certification Number -15 OUTER CASING for mul6taed wells LIT ER tfa - icable
Antler Env. FROM DIAMER ICKNES
MATERIAL
fL ft. in.
Company Name
-16 INNER CASING OR TUBING eothermal closed-loci'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well-Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public It. ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 75.GROUT
—)Irrigation tion FROM TO MATERIAL EMPLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: ft It.
x Monitoring (Temporary) Recovery ft k.
Injection Well:
ft. ft
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test []Stormwater Drainage ft ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets ifnecessary)
- Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilimck tvpe,gmin size,etc.
4.Date Well(s)Completed:8/8/22
0 ft 6 ft- Saprolite and layers of PWR; brown
Well ID#OW-2 6 ft• 55 ft- Partially weathered rock; brown
Sa.Well Location: ft ft.
Ashe Co Landfill (LCID) it ft.
Facility/Owner Name Facility lD#(ifapplicable) ft ft
739 Fred Pugh Rd Crumper, NC 28617 ft ft.
Physical Address,City,and Zip ft. ft lnDfYai3:.�� , fo
Ashe 21.REMARKS
County Parcel Identification No.(PIN) Temporary boring to measure water depth. Boring
abandoned on 8/10/22. Drilling performed by SAEDACCO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if-well field,one lat/long is sufficient) 22.Certificatio
36.5243839 N -81.368688 W `� 9/2/22
6.Is(are)the well(s)oPermanent or [gTemporary Signa' ofCe T fl.d Vell Contractor Date
By signiy this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or x]No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this i.s-a repair,fill out knomw well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional welt 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 site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth-below land surface- 55 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100') construction to the following'
75
-10.Static water level below top of casing: 10. (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: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
lY Well construction method rotary air rota above,also submit one copy of this form within 30 days of completion of well
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
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13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection 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 type: Amount: completion of well construction t I the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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