GW1-2023-00817_Well Construction - GW1_20230113

Print Form- -
WELL:CONSTRUCTION.RECORD (GW-1). For Internal Use Only:
1.Well Contractor Information: ,
Michael Coleman _ __r _
•+-• "-1'4:WATER'ZONES
Well Contractor Name ="- FROM TO DESCRIPTION -
'�. � ? s l'7 J'n"�`'�p ft. ft I i
2992-A
JAN i = 2Q23 ft. ft.
NC Well Contractor Certification Number J :'15.OUTER'CASING for multi cased wells'',OR'LINER'if a livable
Cascade Drilling R;'" FROM TO DIAMETER - THICKNESS- MATERIAL
lrlSi�i'riei�eZ-;�
ia.
p�:n
Company Name
Per EPA
/� Approval
�O"�I 16 INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit# G CPA A t J V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft in
3.Well Use(check well use): ft. ft in.
Water Supply Well: 47.SCREEN .'
FROM . .TO.' DIAMETERS SLOT SIZE THICKNESS .MATERIAL
Agricultural QMunicipal/Public 0 ft. ft. in'
Geothermal(HeatineCooling Supply) DResideritial Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) - • "
18.GROUT. -
IrCI ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It- :55 ft Cement Tremie Pipe
Monitoring. QRecovery ft. - ft.
Injection Well:
ft. ft
Aquifer Recharge DGroundwater Remediation
`19.SAND/GRAVE tiPACK ifa livable _
Aquifer Storage and Recovery [3Salinity Barrier FROM. TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. to
Experimental Technology DSubsidence Control ft.. ft.
Geothermal(Closed Loop) Tracer 20::DRILLING LOG attach additionalslieets if necessa
BGeothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soiltrock type,grain sire,etc.
0 It- 0.5 ft- Asphalt
4.Date Well(s)Completed:6/5/2022 : Well ID#SAD-1 1 0.5 ft- 3.5. ft" Brown fine to med sand some gravel
5a.Well Location: - 3.5 ft 15:5 ft• 'Red to red brown silt
Former Battery Tech 15.5 ft- 20 ft Ochre silt-
Facility/Owner Name Facility ID#(ifapplicable) 20 ft 47 ft : Light brown to gray silt, trace fine sand
305 E. US Highway 64, Lexington, N.C. 47 f` 55 ft MetaquartzDiorite.
Physical Address,City,and Zip - tt. ft
Davidson. 21:REMARKS.. ,
County Parcel Identification No.(PIN) -Ms Is a boHng that was grouted after completion.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
7603372.64 N 1634740.97 w M UCA,C U* a, _' 12/20/2022
6.Is(are)the well(s)JDPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby verb that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ®No with ISA NCAC 02E0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out known well construction information and esplain the nature ofthe 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 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: 655 (ft-) 24a. For All Wells:. Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a 00'and 2@I00') construction to the following: j
10.Static water level below top of casing:26.35 (ft) Division of Water Resources,Information Processing Unit,
1f water level is above casing,,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:611 (in.) 24li.For Iniection Wells: In addition to sending the form to the address in 24a
Sonic 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) Method of test: 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: - Amount: completion of well construction to the county health department of the county
where constructed.
1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016