GW1-2023-02950_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Scott Hunt, Jr
14.,.,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4561-A 15.0 "- f- Fracture
NC
ft. ft.
NC Well Contractor Certification Number
-15.OUTER,CASING(for qhL4"cd'w IiL,�'aeM)OR LINER(if ap
SAEDACCO Inc. FROM To I " I THICKNESS MATERIAL
Company Name 0.0 ft. 114.5 1`- 12 in. I JPvc
BINO(kibili6nuil ildsid,11600':
2.Well Construction Permit FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: .?A7.-SCREEN:'
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ElAgricultural E]Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) 14.5" 29.5 rr. 2 in. 10.010 1 PVC
01ndustrial/Commercial DResidential Water Supply(shared)
01rrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 10.5 ft- Grout Pour
InMonitoring DRecovery 10.5 ft- 12.5 ft- Be6tonite Pour
Injection Well: -
ft., ft.
OAquifer Recharge 0 Groundwater Remediation
19 SAND/GRAVEL-PACK(if iiipli6blif.
[]Aquifer Storage and Recovery OSalinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
CAquiferTest OStormwater Drainage 12.51 ft. 30.0 ft- #0 Sand Pour
OExperimental Technology OSubsidence Control ft. I ft- I I
EiGeothermal(Closed Loop) OTracer -16 DRILLING LOG.(iitta-6h'iidditi6dil'ikeeis if
( typ-g
0 Geothermal(Heating/Cool ing Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color.hardness,soil/mck e rain size,etc.)ft. ft- See Boring Log GWA 1
4.Date Well(s)Completed: 2-7-23 Well ID# GW-1 1 ft. ft.
5a.Well Location: ft. ft.
Upper Piedmont MSW Landfill 7304-MSWLF-1 997 f- e. V i I D
Facility/Owner Name Facility ID#(if applicable) ft. ft.
9650 Oxford Rd., Rougemont, 27572 ft. ft. APR 2 5 2023
Physical Address,City,and Zip ft. ft. lnbtr,-Aan Pr.,na,3&l,9 UrV:i
Person 0953-00-08-2205 21;REMARKS 0=1150111
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:
36.327199 N78.832608 -W
4/12/2023
6.Is(are)the well(s): InPermanent or OTemporary Signature of Certified Well Cont or Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance irith
7.Is this a repair to an existing well: OYes or [INo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of file ofthis record has been provided to the well owner.
repair wider#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-I 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
a n
9.Total well depth below land surface: 0 r_V.V (ft.)
For multiple wells list all depths if different(example-3@200'and 2@ 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 2.68 24a. For All Wells: Original form to Division of Water Resources (DWR),
If wafer level is above casing,use"+ (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Hollow Stem Auger and Air Rotary
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
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018