GW1-2023-00744_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 4459
ft,
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased!!ells)TOR L abe
THICKNESS
�IJAL
GEOLOGIC EXPLORATION 2023 FROM DIAMETER ]Map?LM MATERIAL
JAN ft. in.
Company Name
16,INNER CASING OR TUBING(ge ther a[closed-loop)
2.Well Construction Permit#: ry FROM TO DIAMETER THICKNESS MATERIAL
Lisl all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc'.) 0.0 ft. 5.0 ft- 2.0 SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ElAgricultural CMunicipal/Public 5.0 f" 15.0 ft- 2.0 in.. .010 SCH 40 PVC
DGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
01ndustrial/Corrunercial El Residential Water Supply(shared) 18.GROUT
DIrrigation DWel Is>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 3.0 ft- PORTLAND BENTONITE SLURRY
INMonitoring DRecovery ft. ft.
Injection Well:
ft. ft.
DAquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACKif applicable)
0Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test CStormwater Drainage 4.0 15.0 20-40 FINE SILICA SAND
oExperimental Technology OSubsidence Control
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
oGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,gmin sin,etc.)
0.0 ft- 0.5 ft. ASPHALT
4.Date Well(s)Completed: 09/21/22 WeIIID# MW-6 as ft. 1.0 ft. GRAVEL
5a.Well Location: 1.0 ft- 15.0 ft' SILT
ACME CLEANERS ft. I ft. I
Facility/Owner Name Facility ID#(if applicable) ft. rt.
200 SOUTH BODDIE STREET NASHVILLE 27856 ft. ft.
Physical Address,City,and Zip ft. ft.
NASH 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
350 58' 24.75" N 770 58' 06.48" W
09/22/22
6.ls(are)the well(s): (EPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(Were)constructed in accordance ii-oh
7.Is this a repair to an existing well: OYes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
ll'this is a repair,fill out known well construction infbmuttion and explain the nature of the of'this record has been provided to the well owner
repair under P2/remarks section or on the back of lhis./brin. 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 construction illf()
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15.0 Submit this GW-I within 30 days,of well completion per the following:
loor multiple wells list all depths ifafiffereni(example-3@200'and 2@100')
7.0 24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: (ft.) Information Processing Unit,1617
MSC,Raleigh,NC 27699-1617
ffiraler level is above casing,use
11.Borehole diameter 8.0 (in.) Copy 24b. For Injection Wells: Co to DWR,Underground Injection Control (IUC)
: I
Program, 1636 MSC,Raleigh,NC 27699-1636
AUGER i
12.Well construction method: 24c.For Water Supply and Open_�LoMe im I Return Wells:Copy to the
Geothermal
(i.e.auger,rotary,cable,direct push,etc.) OIL county environmental health depard I nent he county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lvcr 100,000 GPD:Copy to DWR,CCPCUA
Penn it Program,1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources'
Revised 6-6-2018