GW1-2022-10468_Well Construction - GW1_20221207

w
®,
NORTH CAROLINA
ilk
WELL CONSTRUCTION RECORD (GW-1 )
EnvfronmertmfQua(Iry
Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2022-10468
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Shawn Davis [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........ ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ...... ... .........
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
4246 A SHAWN DAVIS FROEHLING&ROBERTSON
2.Well Construction Permit#:
None
List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County,
etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Non-Water Supply Well* Monitoring
Recovery
4.Date well was completed and ID#
................... ................... ............
Date Well Completed* Well ID# Well Yield
11/17/2022 MW-1 (gallons per minute)"
5.Well Location
......... ......... ......... ..... ......... ......... ......... ......... ..... .........

Facility/Owner Name*
Dominion Energy Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Person A98 8
Physical Address* Street Address
Helena Moriah Road
Address Line 2
City State/Province/Region
Mt Tirzah North Carolina
Postal/Zip Code Country
27572 USA
Latitude* 36.2712546000 Longitude*78.8507834000
Decimal degrees Decimal degrees
...........................................................................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.)
17.5 9a.What is the depth of the casing from ground
surface?
For multiple wells list all depths if different
(example-3@200'and 2@100') in feet
11.Borehole diameter:
10.Static water level below top of casing: (ft.) 8.25
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
14.WATER BEARING/FRACTURE ZONES
From To Description
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN

From To Diameter Thickness Material
15.50 10.50 2.00 SCH 40 PVC
in feet in feet in inches
18.GROUT
.....................................................................................................
From To Material Emplacment Method&Amount
6.50 0.00 Portland Cement Tremmie
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
17.50 8.50 Well#2 Gravity
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
17.50 0.00 PWR
in feet in feet
21. Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
................................................................
* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23.Certification
.
Signature of Certified Well Contractor