GW1--04363_Well Construction - GW1_20230707

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information: -
Matt Steele 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 1
4548 A ft. ' ft. -
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS 1 MATERIAL
Geological Resources, Inc. ft. ft.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER _ THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 30 ft, 2 in. sch 40 PVC
List all applicable well permits(i.e.County,State,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 30 ft. 50 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 1 ft' 26 ft. Grout Pour
Non-Water Supply Well: •
26 ft. 28 ft. Bentonite Pour
Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
28 ft. 50 ft. Sand
DAquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology El Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft, 0.5 ft• Topsoil
04/05/2023 MW-1 0.5 ft. 16 ft, Silt
4.Date Well(s)Completed: Well ID#
16 ft. 30 ft. Silt with weathered rock
5a.Well Location: 30 ft. 35 ft Silt
Carolina Composting n/a 35 ft. 50 ft Weathered rock
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
6483 Highway 109 North, Wadesboro, NC ft. ft.
Physical Address,City,and Zip ,r,,,.,
Anson 6496-0048-3734 21.REMARKS ram., _ .tom-_-: }'�_"-
G i%ern A.�4 5.w M `kC a�...
County Parcel Identification No.(PIN)
_ JUI 0 7 2023
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) /� ; 1 ?r^,�qrt,?, l�lih
35.035139 N 80.019896 W �"' 'e. C 4Y25/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 17Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo 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 nature of the
repair under#21 remarks section or on the back 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 form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (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�00'and 2@100) construction to the following:
10.Static water level below top of casing: n/a (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: 5 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Air Rotary24a above, also submit a copy of this form within 30 days of completion of well
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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013