GW1-2022-08966_Well Construction - GW1_20220919

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Jacob L. Rhudy, III 14.WATER ZONES
Wo1lContractor Name FROM TO DESCRIPTION
20 ft. 24 Pt.
NC-4229-B
ft. ft.
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 tt. 0 ft in.
Company Name 2022-�$-29-M V V�^�
-RW5 16.INNER CASING OR TUBING; eothermal closed4bo
2.Well Construction Permit#: V V FROM I 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): R• ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
DAgricultural IDMunicipal/Public 6 ft.. 24 ft' 4° 1tl o.ozo 0.25 pvc
Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) ft. ft. in.
Industrial/Commercial IDResidential Water Supply(shared) '18.GROUT _
,hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 4 ft. 2 ft. bentonite
Monitoring DRecovery 2 ft. 1 fL grout
Injection Well: ft. it.
Aquifer Recharge X Groundwater Remediation
19.SAND/GRAVEL PACK if a'ticable
Aquifer Storage and Recovery Salinity Barrier FROM I TO I EMPLACEMENT METHOD
Aquifer Test IOStormwater Drainage 4 ft- 24 ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) (3Tracer 20.DRILLING LOG attach additional sheets if neeessa
Geothermal(Heating/Cooling Return) f Other(explain under 921 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type rain size,eta
0 ft. 2 ft. fill,gravel,asphalt
4.Date Wells Completed:9/6/22 Well ID#DP-1-R 2 et. 20 ft
() p clayey,sand,chirt
5a.Well Location: 20 ft. 24 ft. hard ss,broken,light brown
Former BP#01363 ft ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. ° �A= �'(
1101 NC HWY 61,Whitsett ft. ft
Physical Address,City,and Zip rL ft. S i 1 9-
Guilford 21.REMARKS
County Parcel ldentificationNo.(PIN) i"' � �
.1f1�
5b.Latitude and longitude in degrees/miriutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification:
36.063487 N -79.564092 u,
Z4�:
�L
6.Is(are)the well(s)X Permanent or OTemporary ry"'igning
lure ofCertified W 1 Contractor Da
this form,I hereby certify that the well(s)was(were)constructed in accordance
.7.Is this a repair to an existing well: DYes or )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:
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
11.Borehole diameter: 8•75 (in.) 24b.For Injection 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:
(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
13a.Yield(gpm) Method of test: 24c.For Water Supply&Inie�lion 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 constructioti!to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Enviromnontal Quality-Division of Water Resources! Revised 2-22-2016
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