GW1-2022-08765_Well Construction - GW1_20220909

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jon Pfohl 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3301-A 36.22 fL >54 ft- I Uppermost'unconfined aquifer
ft. ft
NC Well Contractor Certification Number 15.,OUTER CASING for multi-cased wells OR"LINER of a' licable
Antler Env. FROM TO DIAMETER THICIOVESS MATERIAL
ft ft in.
Company Name 16.INNER CASING OR.. BING eo(hermal,closed-loo
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.
l7:SCREEN
Water Supply Well: FROM TO DIAM FTER F SLOTSIZE 7111C"FSS MATERIAL
Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared)
18.GROUT ',
1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOi7W
Non-Water Supply Well: ft. ft.
x Monitoring (TempOrary) EIRecovery ft k.
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL'PAC K ifa licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft tt.
Experimental Technology 0Subsidence Control ft. &
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sbeets if necessa
Geothermal eating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type.grain slit,etc.
0 ft 4 fL Saprolite and layers of PWR; brown
4.Date Well(s)Completed:8/8/22 Well ID#�W-4 38 ft 52 ft Partially weathered rock; brown
59.Well Location: 52 fL 54 fL Bedrock; Dense, gray
Ashe Co Landfill (LCID) ft ft
Facibty/Owner Name Facility ID#(if applicable) ft fL a
e
739 Fred Pugh Rd Crumper, NC 28617 fL ft. _
Physical Address,City,and Zip ft ft
Ashe 21.REMARKS- n
County Parcel Identification No.(PIN) Temporary boring to measure wate'viftt @oring
abandoned on 8/10/22. Drilling performed by SAEDACCO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certificy n:
36.5250393 N -81.369427 WnJ 9/2/22
6.Is(are)the wells) Permanent or 'Temporary Sigma ofCerdfied Well Contractor Date
By sig ng L form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or )No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and4hat a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 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 site details or well
construction,only I GW-1 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: 54 (ft) 24a. For All Wells: Submit this form within-30 days of completion of well
For multiple wells list all depths if dierem(example-3@200'and 2@l00') construction to the following:
22 36.
10.Static water level below top of casing:. (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27b99-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
air rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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&Iniection Wells: In addition to sending the form to
the address(es) above, also submit 'one copy of this font within 30 days of
13b.Disinfection type: Amount: completion of well construction ti 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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