GW1-2022-08970_Well Construction - GW1_20220919

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jacob L. Rhudy, III 14.WATER ZONES.
FROM TO DESCRIPTION
Well Contractor Name 20 ft. P2 ft. I '
NC-4229-B
ft, rt.
NC Well Contractor Certification Number 15.OUTER CASING(for mulH caged wells OR LINER ifs licable
EnviroCheck of Va, Inc FROM TO DIAMETER THICKNESS MATERIAL
22 ft. 0 ft.
Company Name
16.INNER CASING OR TUBING eothermal closed-loo --
2022-08-29-MWO-RW5
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): R' ft in.
Water Supply Well: FROM REE TO F DIAMETER SLOT SIZE THICKNESS I MATERIAL'
Agricultural OMunicipal/Public 10 it- 22 it- 4• '"' 0.020 0.25 pvc
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. ip•
Industrial/Commercial DResidential Water Supply(shared) ,18.GROUT-
:iri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 5 ft. a ft. bentoniie .
Monitoring E3Recovery 1 ft- 6 ft. grout
Injection Well: ft ft.
Aquifer Recharge X Groundwater Remediation
-,49:SAND/GRAVEL PACK if app licoble
Aquifer Storage and Recovery (0Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage a ft. 22 ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer •�20.DRILLING LOG attach-additional sheets if necessary)
FROM TO DESCRIPTION color,hardness
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) soillrock e, in sit etc.
0 ft. 2 ft. fill,gravel,asphalt
4.Date Well(s)Completed:9/7/22 Well ID#RW-1 RR 2 R• 20 ft. clayey sand,shirt
5a.Well Location: 20 ft, 22 ft. hard as.broken,light brown
Former BP#01363 fr. ft.
Facility/Owner Name Facility ID#(if applicable)'
1101 NC HWY 61,Whitsett ft. ft.
Physical Address,City,and Zip ft. ft S F P 19 2022
Guilford :21.REMARKS'
County Parcel Identification No.(PIN) I ,,eD"'''" 1`lY'n" ^n31Jri1
i v..�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.063326 N -79.564056 W
7
6.Is(are)the well(s)OPermanent or 3Temporary Si a ofCetf Well Contractor' to
B gyring this form,I hereby certify'that the rvell(s)was(were)c trusted in accordance
7.Is this a repair to an existing well: E)Yes or E)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: 22 (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: (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 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 Sunnly&Iniection 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 td the county health ddpartment of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016