GW1--04067_Well Construction - GW1_20230622

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information:
Sam Bowers 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 21.51 ft. 35 ft. light brown to brown SILT
3220-A ft. ft. , .
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap.licable)
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WM0301281 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 20 ft. 2 in' Sch 40 PVC
List all applicable well permits(i.e.('ounty,Slate, Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 ft. 35 ft. 2 in' 0.010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 16 ft• grout pour
Non-Water Supply Well:
lMonitoring ❑Recovery 16 ft• 18 ft• bentonite pour
Injection Well: ft. ft. f -
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
18 ft. 35 ft. #2 Sand Pour
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
ID Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2l Remarks) 0.0 ft• 0.5 ft• topsoil
05/02/2023 Well 0.5 ft. 15.0 ft• red/brown SILT
4.Date Well(s)Completed: Well ID#
15.0 ft• 30.0 ft• light brown SILT
5a.Well Location: 30.0 ft• 31.0 ft• rock layer
Earl Depot 0-011960 31.0 ft• 35.0 it• brown SILT
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2733 Blacksburg Road, Earl, 28038 ..
ft. ft. r';ti..i,.. X.....r e �:! •..,Ii
Physical Address,City,and Zip 21.REMARKS
Cleveland 2543353334 JUN 2 2 2023
County Parcel Identification No.(PIN)
bfl.1te,&i:ejPI ?ram-,,�.._ g:';zz
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: Qt° .30(43
(if well field,one Iatllong is sufficient)
35.194380 N 81.533250 W 05/02/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this forte,I hereby certify that the well(s) was(were)constructed in accordance
with/5A NCAC 02C.0100 or I5A NCAC 02C.0200 Well C'onstructton Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to the well owner.
Ifrhis is a repair,fill out known well construction ttrformalion and explain the nature of the
repair under i2/remarks section or on the hack ofthisfbrm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or Iron-water supply wells ONLY with the same construction,you can
submit one firm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 35 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'cold 2 a l o0') construction to the following:
10.Static water level below top of casing: 21 .51 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use":" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
Solid Stem Auger
12.Well construction method: 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
(gpm) 24c.For Water Supply&Injection Wells:
m 13a.Yield Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
' constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013