GW1-2022-10456_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ronald F. Barron V R i 14.WATER ZONES
Well Contractor Name NOVQ22 FRONT TO DESCRIPTION
IV �
2091-A ft. ft.
NC Well Contractor Certification Number tfluiili=yi�� ?ate„��
Cl';;t�j C UI:N
} Q p �7 '15.OUTER CASING for multi-cased wells OR LINER if a -liable
Piedmont Industrial Services FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
A6.INNER CASING OR TUBING ieothermal closed-loop)
2.Well Construction Permit#: /-/�" FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) +3 ft. 9.5 ft. 2 in. Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [:)Municipal/Public9 5 f• 19.5 ft' 2 in. .010 'Sh 40 PVC
__ Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) -18.GROUT
Im ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 5 ft. 7 ft. 3/8 Bentonite chips trernie
x Monitoring (©Recovery 0 ft. 5 ft. Concrete Poured
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
` 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 7 rt• 19.5 ft- #3 filter sand Tremie
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessn
FROM TO DESCRIPTION(color,hardness,soil/rocke, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 rt• 15 rt• reddish Brn silty clay
4.Date Well(s)Completed:11-7-22 - Well ID#GP-4 15 rt. 20 ft. Tan sandy silty clay
5a.Well Location: ft. ft. BT @ 20
Wilson County Solid Waste N/A ft. ft.
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' 57" N 77 51' 44" W ` �A•
_/_�G�" `/-
6.Is(are)the well(s)[ Permanent or [3Temporary 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: []Yes or [qNo 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 if necessary.
drilled:N/A SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 19.5 ft.
P ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
Fornndtiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:13.04 Division of Water Resources,Information Processing Unit,
If water level is above casing,ruse"+" 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
.Well construction method: Auger above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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 construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016