_Well Construction - GW1_20230315 (44)

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor information:
Brian James Bellis 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
NCWC 3510-A 3.95 ft. >10 ft. Water table
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER(if a i licable
WithersRavenel, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft 3.0 ft 2.0 i" Sch. 40 PVC
A 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit# FROM TO DIAMETERTHICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate, Ilariance,etc) ft. ft. in.
3.Well Use(check well use): ft• rt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public 3.0 ft- 5.5 ft. 2.0 '"• 10 Sch.40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 1.5 ft. Concrete Pour
X Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK(ifa licable
Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage 2.5 ft- 5.9 ft. Torpedo Sand I Pour
Experimental Technology Subsidence Control 1.5 ft- 2.5 ft- Bentonite Chips I Pour
eothermal(Heating/Cooling Return) (explain under#21 Remarks)
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color•hardness,soitrock ndn size,etc.)
0 ft. 1.0 ft- Topsoil
4.Date Well(s)Completed:3/1/2023 Well ID#MW-2 1.0 ft* 5.0 ft, Silty sand excavation backfill
5a.Well Location: 5.0 ft. 5.9 ft. Gray micaceous schist
Glen Coleman's Store 0-0-6043 ft. ft. _
Facility/Owner Name Facility iD# ifa licable ft. ft. (" '
444 Rabbit Bottom Rd, Warrenton NC ft. ft.
02,3
Physical Address,City,and Zip
ft. ft. t r r_
Warren 2971367599 21.REMARKS 71
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
36.265859 N -78.072115 W ,C 3/2/2022
6.Is(are)the well(s)�Ix Permanent or Temporary Signature of Certified W I Co actor Date
By signing this form,1 hereby certify that the ivell(s)was(here)constructed in accordance
7.Is this a repair to an existing well: E)Yes or x)No irith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/'this is a repair,fill oat known hell construction information and explain the nature of the copy ofthis record has beenprovided to the use/1 owner.
repair under n21 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-i 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: 5.90 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple hells list all depths i'dii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below to of casing:2.13 ft.
P g� ( ) 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:3.0 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Auger above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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 SuDDIv&Injection 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