GW1-2022-10693_Well Construction - GW1_20221205

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: !
1.Well Contractor Information: (.
Brian James Bellis '14.WATERZONES' 1
FROM TO DESCRIPTION
Well Contractor Name 4.62 ft. >10 ft. Waterjtable
NCWC 3510-A ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells)OR LINER i£a licable
WithersRavenel, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft2.55 ft- 2.0 1 Sch. 40 PVC
A 16.1NNER,CASING OR TUBING �eothermal closed-loo
2.Well Construction Permit#:N FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
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3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIA-JnL
Agricultural Municipal/Public 2.55 ft- 7.55 f" 2.0 ', 10 Sch.40 PVC
-_ Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. it•
Industrial/Commercial Residential Water Supply(shared) 18.GROUT'
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 0 ft- 1.5 It- Concrete Pour
x Monitoring [3Recovery fr. ft.
Injection Well: fr. ft.
Aquifer Recharge [Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 'Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 1.5 ft 7.55 ft. Sandi UST excavation backfill
Experimental Technology Subsidence Control ft. ft.
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Geothermal(Closed Loop) Tracer 20.DRILLING LOG"attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) F1 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
0 ft- 1.0 ft- Topsoil
4.Date Well(s)Completed:11/18/2022 Well ID#MW-2 1.0 ft- 7.55 ft, Silt sand clean excavation backfill
5a.Well Location: fr. ft. ; n A k
Fast Pace Facility 0-0-20836 ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft H C 3 V 2022
6451 Hwy 301 N, Battleboro ft.
Physical Address,City,and Zip ft. ft J1.'>r0,/ 'QZ
Nash 386400916375
21.REMARKS
County Parcel Identification No.(PIN) tJ[-h.75
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36.055460 N -77.749243 W - I� 11/30/2022
6.Is(are)the well(s)ox Permanent or Temporary Signature ofCertifi&A.W611 Contractor I ' Date
By signing this form,1 hereby certijy that the wells)ivas(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EJNo ,vith.15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well.Construction Standards and that a
(flhis is a repair,fill out known well construction information and explain the nature of the copy oflhis record has been provided to the well owner.
repair under#11 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS;
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9.Total well depth below land surface: 7.55 (II-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJferem(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:6.62 (ft.) Division of Water Resources,Information Processing Unit,
Lf,vater level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:3. (in.) 24b.For Infection 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: j
(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&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: NA Amount: NA completion of well construction to the county health department of the county
where constructed. j
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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