GW1-2023-02002_Well Construction - GW1_20230227

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WELL CONSTRUCTION RECORD(GW-11 �4� F_� For Internal Use Only:
1.Well Contractor Information:
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Chris Ruffer A4.3VATERZONES
Well Contractor Name FROM TO DESCRIPTION
4223-A 41.34 ft• 52.3 ft-
ft. ft. !
NC Well Contractor Certification Number
_15.OUTERCASING:forinulti4died4e11s)OR LINER ifa` `'Gcable'
SAEDACCO, Inc. FROM TO- DIAMETER THICKNESS MATERIAL
0 ft- 42.1 ft- 12 i" SCH-40 I PVC
Company Name
=16.INNER CASING,OR TUBING eothermal closed-loo'-'`_
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,ere.) ft. It.
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3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS' MATERIAL
❑Agricultural ❑MunicipaVPublic fr. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft- in
42.1 52.1 2 0.010 scH-00 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) -
ll:GROUT'
❑Irrl ation ❑Wells>100,000GPD FROM To MATERIAL- _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 38.8 f- Grout Tremie
InMonitoring ❑Recovery 38.8 ft- 4 1.1 ft- Bentonite Pour
Injection Well:
tr. fr.
❑Aquifer Recharge ❑Groundwater Remediation 19. 4
❑A uifer Storage and Recovery ❑Salini Barrier FROM D/GRAVEL PACK ifa licablc ;.; r ".•' '
q g ry tY FROM TO MATERIAL EMPLACEMENTM1(ETHOD
❑Aquifer Test ❑StormwaterDrainage 41.1 ft. 52.3 ft- Sand. Pour
❑Experimental Technology ❑Subsidence Control ft. tr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach'edditional`sheets if ireceisA :';,'•: ;':y-i:_^i.::
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness.soil/rock type.gmin sim,etc.
�p� ft. ft- See Boring Log GW-22
4.Date Well(s)Completed: 12/15/22 Well ID#G V V-22 ft• ft. i
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5a.Well Location: ft. ft.
Uwharrie Regional MSWLF 6204-MSWLF-1995 tr. ft. ..�-' ..v ra •;
Facility/Owner Name Facility ID#(if applicable) fr. ft. i - 9
500 Landfill Rd, Mt Gilead, NC, 27306 fr. fr.
Physical Address,City,and Zip ft. ft. Una
Montgomery 21.REMARKS
,:'-'.cs:. --
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.335827 N -79.971706 W C/uz�
2/20/2023
6.Is(are)the well(s): In Permanent or ❑Temporary Signature of Certified Contractor Date
By signing this form,I hereby certify that the ire//(s)u-as(here)constructed in accordance with
7.Is this.a repair to an existing well: ❑Yes or PJNo 15A NCAC 02C.0100 or 15A NCAC 02C:0200 Well Construction Standards and that a copy
Ifihrs is a repair,fill our known ivell construction information and explain the nature of rile ofthis record has been provided to the I h 'ell 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 52.30 (ft.
Formultiple ivel►s list all depths ifdoerent(example-3 a 200'and 2 a 100') ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:41.34 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifu'ater level is above casing,use••+'• Information Processing Unit,1'617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection W R ells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NCB 27699-1636
12.Well construction method: Sonic 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh;NC 27699-1611
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13b.Disinfection type: Amount: 1
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018