_Well Construction - GW1_20230315 (46)

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Brian James Bellis 14.WATER ZONES t
Well Contractor Name FROM TO DESCRIPTION
NCWC 3510-A 2.13 ft. >10 ft• Water table
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for wolf'-cased wells OR LINER(if a licable
WithersRavenel, Inc. FROM TO DL►METIiR THICIGNEsS bL►TERIAL
Company Name
0 ft. 3.5 ft. 2.0 Sch. 40 PVC
NA 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,17arianc•e,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN '
FROM TO DIAMETER SLOTSIZE THICICVESS MATERIAL
Agricultural Municipal/Public 3.5 ft. 6.0 ft. 2.0 in. 10 Sch.40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial D Residential Water Supply(shared) 18.GROUT
irrl at1On FROM I TO MATERIAL E,MPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1.5 ft- Concrete Pour
x Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery 19.SAND/GRAVEL PACK(if applicable)
Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage 2.5 ft- 6.40 ft. Torpedo Sand Pour
Experimental Technology D Subsidence Control 1.5 ft. 2.5 fl• Bentonite Chips Pour
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVrock type,grain size,etc.
0 ft- 1.0 ft- Topsoil
4.Date Well(s)Completed:3/1/2023 Well ID#MW-1 1.0 ft. 5.0 ft. Silty sand excavation backfill
5a.Well Location: 5.0 et. 6.4 ft, Orange clay and grey schist
Glen Coleman's Store 0-0-6043 ft. ft. J;- ,�.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
444 Rabbit Bottom Rd, Warrenton NC ft. ft. MAP, i Z i
Physical Address,City,and Zip ft. ft.
Warren 2971367599 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Certification:
36.265834 N -78.072190 W -3/2/2022
6.Is(are)the well(s)�Ix Permanent or Temporary Signature of Certified WeN22aw6ctor Date
By signing this form,I hereby certo that the well(s)was(mere)constnuc(ed in accordance
7.Is this a repair to an existing well: []Yes or [gNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ifthis is•a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 remarks section or au 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: 6.40 (fl•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depilis ifdiJferent(example-3@200'and 2 rr 100') construction to the following:
10.Static water level below to of casin 2.13 ft.
P g� ( ) Division of Water Resources,Information Processing Unit,
lf'materlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:3.0 (in.) 24b. For Iniection 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 Supply&Inieciion 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