GW1--04068_Well Construction - GW1_20230622

r
' 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 20.70 ft, 35 ft. 1 light brown SILT
3220-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS 1 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.County,Stare, 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 ❑MunicipaVPublic 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 ft. ft.
Non-Water Supply Well: 0 16 grout pour
16 ft. 18 ft. bentonite • pour
OMonitoring ❑Recovery
Injection Well: ft.. ft;-
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 18 tt 35 ft. #2 Sand Pour
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0.0 ft- 0.5 ft. topsoil
05/02/2023 Well 0.5 ft• 18.0 4- red/brown SILT
4.Date Well(s)Completed: Well ID# 18.0 ft• 35.0 ft• light brown SILT
• 5a.Well Location: ft. ft. e 1°' ^*
Earl Depot 0-011960 ft. ft. °=` ` �% -
•
Facility/Owner Name Facility lD#(if applicable) ft. ft. JUN 2023
2733 Blacksburg Road, Earl, 28038 ft. ft.
Physical Address,City,and Zip jni riW 3 ti i 7r,-,r nan,..3::m.:
Cleveland 2543353334 21,REMARKs �`t°`Ca'�'�,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
35.194380 N 81.533250 • W 05/02/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): CIPermanent or ❑Temporary y signing form, y certifywell(s)
l3 ci nin this I hereby certi that the was were constructed in accordance
with 15A NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction 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.
If this is a repair,fill out known well construction information and explain the stature of7he
repair under i 2i remarks section or on the hack of this form. 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 non-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 a,200'and 2@I00') construction to the following:
10.Static water level below top of casing 20.70 (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
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
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