GW1-2022-08967_Well Construction - GW1_20220919

Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I'
i
1.Well Contractor Information:
Jacob L. Rhudy, III M WATER ZONES
FROM- TO DESCRIPTION
Well Contractor Name
20 ft. 24 ft.
NC-4229-B
ft. ft.
NC Well Contractor Certification Number .15.OUTER CASING for multl cased we0s OR LINER if a licable
EnviroCheck of Va, Inc FROM To D F THICKNEss MATERIAL
24 ft. p ft. ! in.Company Name 16.INNER CASING OR TUBING' rmai eothe closed400
2.Well Construction Permit#:2022-�8-29-MWO-RW5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FR•OMREE TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 5 D• 25 ft* q• iii. 0.020 0.25 pvc
Geothermal(Heating/Cooling Supply) Okesidential Water Supply(single) ft ft ;n•
industrial/commercial E3Residenfial Water Supply(shared) 18.GROUT
rxi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 5 ft. 3 ft bentonite
Monitoring Recovery 3 ft. t ft grout
Injection Well:
tt, it
Aquifer Recharge X Groundwater Remediation
SAND/GRAVEL PACK(if a- Bcablc "
Aquifer Storage and Recovery !DSalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 5 ft. 25 ft
Experimental Technology Subsidence Control ft• ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessar'
es,
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardn ssoillrocke, ram size,etc.
0 D• 2 tt• fill,gravel,asphalt
4.Date Well(s)Completed:916/22 Well ID#RW-4 2 ft. 20 ft. clayey,sand,shirt
$s.Well Location: 20 ft. 25 ft hard ss,broken,light brown
Former BP#01363 ft. ft _
Facility/Owner Name Facility ID#(if applicable) ft. ft. ' ,'L.— ':
1101 NC HWY 61,Whitsett ft. ft _
Physical Address,City,and Zip ft ft — v
Guilford . 1.REMARKS ,.y
;. ,ti...
County Parcel Identification No.(PIN) recoVPry Wellfit,°'C�l% QO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
36.063487 N -79.564092 W
l C q I/ 2Z
6.Is(are)the well(s)oPermanent or OTemporary Signs e f erti red Well C ctor Date
By si ring this form,1 here ertify'that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EX 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: 25 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(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,
Ifwater level is above casing use"+" 1617 Mail Service!Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.75
(in.) 24b.For Iniection 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
1
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'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
f