GW1-2022-10692_Well Construction - GW1_20221205

( _ Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
Brian James Bellis 14.WATERZONES
Well Contractor Name
FROM TO DESCRIPTION
NCWC 3510-A 3.75 ft- >10 ft- Waterltable
ft. ft. I i
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased'wells OR LINER if a n licable)
WithersRavenel, Inc. FROM TO DIAMETER THICKNESS ,MATERIAL
0 rt. 1.7 ft. 2.0 1 i" Sch. 40 PVC
Company Name
/� 16.INNER CASING OR TUBING geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,Slate, Variance,etc.) ft. ft. 1 in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public 1.7 ft• 6.70 ft, 2.0 in, 10 Sch.40 PVC
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft ft iu.
IndustriaUCommercial DResidential Water Su (shared)
Supply 18.GROUT
rl Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 1.5 " Concrete Pour
x Monitoring 13 Recovery ft. ft.
Injection Well:
fr.Aquifer Recharge ®Groundwater Remediation tt.
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage 1.5 ft. 6.70 ft- Sand UST excavation backfill
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) ©ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soiVrock rain size,etc.
0 ft- 1.0 ft. Topsoil
4.Date Well(s)Completed:11/18/2022 Well ID#MW-1 1.0 ft. 6.7 ft. Silty sand clean excavation backfill
ft. ft.
5a.Well Location:
Fast Pace Facility 0-0-20836 ft. ft. t"-J'tii-1--Z a '_
Facility/Owner Name Facility iD#(if applicable) ft. fL _t,
6451 Hwy 301 N, Battleboro ft. ft. - r' L.
Physical Address,City,and Zip
ft. ft. r --' F'at3 U11.0
In;cat+��n r:,,���...
Nash 386400916375 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification'
36.055362 N -77.749340 W
11/30/2022
6.Is(are)the well(s)�Ix Permanent or Temporary Signature ofCe ified ell Contractor Date
_ _ ,By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or xBNo with I5A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
/-this is a repair,fill out known well construction information and explain the nature of the copy of dds record has been provided to the well owner.
repair under#21 remarks section or on the back of this fornn.
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: 6.70 (ft-) 24a. For All Wells: Submit this l'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: i
75
10.Static water level below top of casing:3. (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:3•0 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Installed in UST Excavation while backfilling 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) NA Method of test: NA 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: NA Amount: NA 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