GW1-2022-08965_Well Construction - GW1_20220919

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
Jacob L. Rhudy, 111 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC-4229-B 20 fr. 24 fL
ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable.
EnviroCheck of Va, Inc FROM TO DIAMETER THICKNESS MATERIAL
24 ft. 0 ft. io.
Company Name
ZOZZ-O8-Z9-MWO-RW5 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits C.e.UIC,County,State,Variance,etc.) ft. ft. in,
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural DMunicipal/Public 6 fL 24 R• 4" in. 0.020 0.25 pvc
Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) fL ft.
hidustrial/Commercial Residential Water Supply(shared) I8,GROUT
"Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 4 n• 2 ft. bentonite
Monitoring I]Rccovery 2 ft. t ft. grout
Injection Well:
ft. ft. ,
Aquifer Recharge iX Groundwater Remediation
19.SAND/GRAVEL PACK it applicable)_
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage 4 tt. 24 tt.
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) FROMI TO DESCRIPTION color,hardness soil/rock type,grain size,etc
0 ft. 2 ft, fill,gravel,asphalt
4.Date Well(s)Completed:9/6122 Well ID#RW-3 2 ft. 20 ft• clayey sand,shirt
5a.Well Location: 20 ft. 24 ft. hard as,broken,light brown
Former BP#01363 ft. ft
Facility/Owner Name Facility ID#(if applicable)
ft. ft. ��.k__�h,s C..9 "tr E B
1101 NC HWY 61, Whitsett ft. ft. _
Physical Address,City,and Zip
ft. ft.
Guilford 21.REMARKS 1 -;;.,uC-i U roi
County Parcel Identification No.(PIN) recovery wpIl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
4�
36.063534 N -79.564120 Wgg�_� - !/ ��6.Is(are)the well(s)J@Permanent or 13Temporary ry,ig,ning
cure ofCertified Well Infractor D e
this form,I hereby certify that the well(s)tivas(tivere)constructed in accordance
7.Is this a repair to an existing well: QYes or IX No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that 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#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 site details or well
construction,only 1 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: 24 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following: I
10.Static water level below top of casing:7 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 8.75 010 24b.For Infection Wells: In addition to sending the form to the address in 24a
auger above,also submit one copy"of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le,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
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 constructions to 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