GW1-2022-08968_Well Construction - GW1_20220919

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,
1.Well Contractor Information:
Jacob L. Rhudy, 111 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
20 11- 24 ft. I ;
NC-4229-B
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
EnviroCheck of Va, Inc FROM TO DIAMETER THIC.NEss MATERIAL
23 ft. 0 ft. in.
Company Name
2022-08-29-M WO-RW5 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM I To I 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): f1• ft. in.
17.'SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural DMunicipal/Public t2 ft. 23 ft- 4- " 0.020 0.25 pvc
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/CommercialResidential Water Supply(shared) 18.GROUT
rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 10 h• 12 ft. bentonite
Monitoring DRecovery 1 ft, 10 ft. grout
Injection Well: ft. ft.
Aquifer Recharge X Groundwater Remediation
'd9.SAND/GRAVEL PACK if applicable)
'
__ Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
-'Aquifer Test DStormwater Drainage 10 ft- 23 ft.
Experimental Technology 0Subsidence Control ft. ft.
RGeothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ; Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rack type,gruln size,etc
0 ft. 2 ft, fill,gravel,asphalt
4.Date Wells Completed:9/7/22 Well ID#RW-5 2 ft. Z0 ft.
()Com p clayey sand,chirt
5a.Well Location: 20 R• 23 ft. hard as,broken,light brown
Former BP#01363 ft f° F .� -, y -n
Facility/Owner Name Facility ID#(if applicable)
1101 NC HWY 61,Whitsett ft. I ft. SF P 9 2�22
Physical Address,City,and Zip
ft. ft.
Guilford '21.REMARKS
County Parcel Identification No.(PIN) recovery well
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.063378 N -79.564074 W
9/40/� :
�i ZZ
6.Is(are)the well(s)oX Permanent or OTemporary ry,igning
tore of C rtified Well Co❑tractor, to
this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or MNo with 15.4 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 io 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 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: 23 (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 m. i
(� ) 24b.Far Infection Wells: In addition to sending the form to the address in 24a
auger
aU9 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&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
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