GW1-2022-09411_Well Construction - GW1_20221007

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Wesley J. Sorrells
14:WATER ZONES •,-
WellContmctorName FROM TO I DESCRIPTION
3577 ft fL
ft. ft.
NC Well Contractor Certification Number ;15.OUTER'CASING focmulh cased;wells:OR`LINER'if all
Terraquest Environmental Consultants FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16rINNERCASING`ORTUBING;'°eo'the 16id
2.Well Construction Permit#: FROM TO L DIAMETER THICKNESS IA MATERL
List all applicable well construction permits(i.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 Y SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) Dj Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROIIT'
r
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring EIRecovery ft. ft.
Injection Well:-— -- - —
ft. ft.
Aquifer Recharge Groundwater Remediation
J Aquifer Storage and Recovery SalinityBarrier ;l9'SAND/GRAVEL'-PACK if a D]i&ble
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
!Experimental Technology Subsidence Control ft. ft.
J Geothermal Closed Loo -
( p) J Tracer il20;DRILLING;LOG,attachaddihoneh`sheetsifuec'essai
Geothermal(Heating/Cooling Return) (explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUrock twin size ete.
0 & 15 ft. LEAN CLAY
4.Date wells)Completed:5/3,23-24/2;well ID#I NJ 1-8 15 ft- 30 ft SILT
ft.
Sa.Well Location: ft. -
�, rc
ft.00-0-0000022386 _L&L#5' L U`
Facility/Owner Name Facility ID#(if applicable) ft. ft. OCT 0 7
2022
109 W. Nash St. Bus. 64 Spring Hope NC. ft. ft.
Physical Address,City,and Zip ft ft. �Ilt li i tea " C Uf i;
Nash 2769062957763
County Parcel Identification No.(PIN) Temporary borings for'injection.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.944339 N -78.112804 W Lt)J 5/25/22
6.Is(are)the well(s)[ Permaneut or OTemporary Signature ofCcrtifielWell Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or MNo 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:8 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd�erenI(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:20 (ft.) Division-of Water Resource's,Information Processing Unit,
if water level is above casing,use"+" 1617'Mail'Se'vice Center,Raleigh,NC 27699-1617
11.Borehole diameter: 5 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12. direct push above,also submit one copy of this Iform within 30 days of completion of well
(i.e.Well construction method:.auger,rotary,cable,direct push construction to the following:etc.) h
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&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 to i e county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016