GW1-2022-10454_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ronald F. Barron Il
eft
ma ft:.l "14.'WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2091-A NOV 1 8 2022
ft. ft.
NC Well Contractor Certification Number If1�4P3+}�,e l? ;*^;,,y%` j(�r 15.OUTER CASING for multi-cased wells OR LINER'if b livable
Piedmont Industrial servlces�yd.O,"3� FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name /� 16.INNER CASING OR TUBING 'eothermal closed-loo
N
2.Well Construction Permit#: " -/- - FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) +3 ft. 10 ft. 2 in' Seh 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 10 ft. 20 ft. 2 in. .010 Sh 40 PVC
_ Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft. in.
_ Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. 8 ft. 318 Bentonite chips tremie
X Monitoring Recovery 0 ft. 6 ft. Concrete Poured
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19sSAND/GRAVEL PACK ifa livable__
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 8 ft 20 ft #3 filter sand Tremie
Experimental Technology Subsidence Control
Geothermal(Closed Loop) E3Tracer .20.DRILLING LOG attach additional sheets if necema
RFROM TO DESCRIPTI0N(color,hardness,soil/rock type, rain size,etc.
Geothermal(Heating/Cooling Return) - Other(explain under#21 Remarks)
0 ft 15 ft reddish Bm silty clay
4.Date Well(s)Completed:1 1-7-22 Well ID#GP_6 15 ft. 20 ft re !3andy silty clay
5a.Well Location: ft. ft. 13T @0 20
Wilson County Solid Waste N/A ft. et•
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2400 Hwy 42E,Wilson 27893 ft. ft.
Physical Address,City,and Zip
ft. ft.
Wilson N/A 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 43' 19" N W 77 51' 56" —f
y
6.Is(are)the well(s)ox Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or X)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 io the well owner.
repair:coder#21 remarks section or on the back of this fornn.
23.Site diagram or additional well details:
S.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:N/A SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3 r@i 200'and 2 c1 00') construction to the following:
10.Static water level below top of casing:14.38 (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: 10 (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:
(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& Infection 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