GW1-2023-00818_Well Construction - GW1_20230113

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Print Form
WELL.CONSTRUCTION RECORD (GW-1)- - For Internal Use Only: f- k
1.Well Contractor Information:
Michael Coleman WATER ZONES. '
Well Contractor Name FROM TO DESCRIPTION -
2992-A -�_
ft. ft.
V u sg E�� ft. ft. !i
NC Well Contractor Certification Number .15.OUTER CASING for multi cased wells ORLINER ifa 'livable - "
Cascade Drilling JAN 1 2OZ3 FROM TO DIAMETER ._ THICKNESS MATERIAL
ft. ft
Company.Name _ �r� L!f'ic1,
n .i„ 1 ' / 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: Per.EP A� .FROM TO. DIAMETER THICKNESS MATERIAL
List all applicable.well construction permits(i.e..UIC,County,State,Variance,etc.). ..
ft. ft. in
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public . 0, ft. ft. in
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) .. ft. ft. in:
Industrial/Commercial [3Residential Water Supply(shared) 18.GROUT
kTi ation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:. .0 f`- :55 . ft Cement Tremie Pipe.
Monitoring- Recovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation-
-19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test r1Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
_ Geothermal(Closed Loop) Tracer 20.DRILLING LOG'attach additional,'sheets if necessary).
Geothermal.(Heating/Cooling Return) rl Other(explain.under#21 Remarks) FROM TO. DESCRIPTION color,hardness,soiUrock type,gmin size,etc.
0 ft• 0.5- ft Concrete
4.Date Well(s)Completed:6/3/2022 Well ID#SAD-09. 0;5 ft 1 fL Q.raysilty fine sand with ravel
5a.Well Location: 1 ft- 2'' f`' Li d ht�brown fine silly sand
Former Battery Tech 2 f` 3.5 ft- Dark red clayey silt, some fine sand
Facility/Owner Name Facility ID#(if applicable) 3.5 f`- 20.5 ft Red fine sandy silt, some medium sand
..: 20.rf1' 4H ` f`' Light red brown fine to medium sand,some silt
305 E. US Highway 64, Lexington, N..0
Physical Address,City,and Zip 48 f`' 55 ' f`' Granite
Davidson 21REMARKS .'
County Parcel Identification No.(PIN) TWS IS a boring that Ni as grouted after Com lGtion.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:.,.
(if well field,one lat/long is sufficient) 22.Certification:
760377.13 .N 1634905.29 w
M i.►t,& c4�{.Q.tivl4*11; 12/20/2022
6.Is(are)-the well(s)JDPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were);constructed in accordance
7:Is this a repair to an existing well: '[3Yes or ®No with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards.and that a
If this is a repaii,fill out known well construction information and explain the nature.of the copy of this record has been provided ld he 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: 55 . (ft-)_ 24a. For All Wells:, Submit this form,within 30 days of completion of well- .
For.multiple wells list all depths if dierent(erample-3 rt 00'and 1Ca 100') construction to the following:
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10.Static water level below top of casing:25.30 (ft.) Division of Water Resources,Information Processing Unit,'
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6" (in.) 246.For Iniectioh Wells: In addition to sending the form to the address in 24a
�+ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Sonic construction to the following: 1
(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&Iniectiori ------ ki addition'fo sending the form to
the address(es) above, also submit Oe 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_. Ir J
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016.
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