GW1-2023-01637_Well Construction - GW1_20230213

Print Form-
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Tynan "34.WATER ZONES- r '
Well Contractor Name FROM TO I DESCREMON
2725-A > ::'v' T, _ 31 ft- 38 ft silty san6
i � J 1n= u
ft. ft
NC Well Contractor Certification Number FEBIS.OUTER CASING for multi cased'wells OR LINER if a 6cable
ETt1 2 FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name
IrtiC•ir';::c:>C7 �Ei ;•'• ;��1�(;;1 16.INNER CASINGORTUBING eothermnlclosed-1
2.Well Construction Permit#: ICV • uI G FROM I TO I DIAMETER I THICKNESS ...I.MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) ft 1$ ft 2 " in SCh40 PVC
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER: SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 18 fL 38 ft' 2 i" 0.010 SCh40 PVC
Geothermal(Heating/Cooling Supply) 'OResidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 3 ft concrete pour
x Monitoring []Recovery 3 __ft 16 ft bentonite;_ _.pour-through augers _
Injection Well: ft ft
Aquifer Recharge 0Groundwater Remediation
'19.SAND/GRAVEL PACK(ifioblicablel
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test [38torinwater Drainage 16 ft 38 ft #2 silica sand pour through augers
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
ft ft See Consultant's log
4.Date Well(s)Completed:2/2/23 Well ID#MW 5 ft ft
Sa.Well Location:
ft. ft "
D&M Grocery ft. ft
Facility/Owner Name Facility D)#(ifapplicable) ft ft
6066 NC-704, Sandy Ridge, 27046 ft. &
Physical Address,City,and Zip & ft
Stokes 21.REMARKS
County Parcel Identification No.(PIN) Finished at surface with flush well cover and 2'x2'
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: concrete pad.
(ifwcll field,one lat/long is sufficient) 22.Certification:
36 28 17.033 N -80 06 02.945 W r
/ 2/8/23
6.Is(are)the well(s)Ox Permanent or OTemporary Signature ofCcvIed 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: ®Yes or X No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this 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 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 j
9.Total well depth below land surface: 38 (ft) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:31 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter:8.5 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
auger above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: g 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&Iniectionl 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016