GW1-2023-02003_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Ruffer AC WATER20NES
Well Contractor Name FROM TO f DESCRIPTION
4223-A - 32.03 ft- 50.35 ft-
ft. ft.
NC Well Contractor Certification Number
'AS.'�OIJTER CASING(for rfiufti4asid i0ells)
SAEDACCO, Inc. FROM OR LINER
J TO 1 DMAIETER AMATERIAL
Company Name 0 ft- 140.15 ft- 12 i in. I SCH-40 PC
16.1NNER.CASINGOR TUBING('eotherm' al dosid-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits 0.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
F
Water Supply Well: FROM
FROM TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
OAgricultural OMunicipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) OResidential Water Supply(single)
40.15f'- 50.15ft- 2 in. 0010 ISC-1-1-40 PVC
1:11ndustrialitCommercial 0 Residential Water Supply(shared) -IS.GROUT
01rrigation ElWells>100,000 GPD FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
0 ft- 34 ft- Grout' Tremie
InMonitoring ORecovery 34 ft- 38 ft- Bent6ni I te Pour
Injection Well: ft. ft.
OAquifer Recharge 13Groundwater Rentediation
19.-SAND/GRAVEL PACK(if
oAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
DAquifer Test OStormwater Drainage 38 ft- 155 ft. Sand JPour
0 Experimental Technology OSubsidence Control fr.
ft.
OGeothermal(Closed Loop) OTracer 20.-DRILLING LOG(attach additional sheets if riecessa
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltruck type.grain size,etc.)
ft. ft- See Boring Log GW-23
4.Date Well Completed: 12/15/22 Well ID#OW-23 ft. ft.
5a.Well Location: ft. ft.
Uwharrie Regional MSWLF 6204-MSWLF-1 995 ft. ft.
Facility/Owner Name Facility ID9(if applicable)
ft. ft. FEB 9, :1 2023
500 Landfill Rd, Mt Gilead, NC,,27306 ft. ft.
Physical Address,City,and Zip ft. ft.
_7
Montgomery ;21.-REMARKS777 7 T
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
35.342640 N -79.969463 W
&Wlzr�� 1 2/20/2023
6.Is(are)the well(s): [nPermanent or oTemporary Signature of Certified lWontractor Date
By signing this form,I hereby certify 1hai the ivell()was(were)constructed in accordance with
7.Is this a repair to an existing well: 13Yes or (INo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a COPY
If this is a repair•fill out known well construction information and explain the nature of tine of this record has been provided to the ii;el/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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: 50.35 24.SUBMITTAL INSTRUCTIONS
_(ft)
* Submit this GW-1 within 30 days of well completion per the following:
F-or multiple wells list all depths#*dfferem,(example-3@200'and 2@100) 1
10 . 32.03 24a. For All Wells: Original form to Division of Water Resources (DWR),
.Static water level below top of casing (ft.)If water level is above casing,use"+ Information Processing Unit,1617MSC,Raleigh,NC 27699-1617
11.Borehole diameter.• 6 (in.) 24b.For Infection Wells:Copy to bwR,Underground injection Control(lUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Sonic I �
,etc.) 24c.For Water Supply and Openrotary, �-Loop Geothermal Return e Copy to the
installed
(i.e.auger,rotary,cable,direct push county environmental health department of the county where Wells:
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingl over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of water Resources Revised 6-6-2018