GW1--04394_Well Construction - GW1_20230707

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Matt Steele 14.WATER ZONES'
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
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 I MATERIAL
Geological Resources, Inc. ft. ft. in. I
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO • DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 37 ft. 2 1°' 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 37 ft. 57 ft. 2 1°' 0.010 sch 40 PVC
El Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL • EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 33 ft• Grout Pour
Non-Water Supply Well:
33 ft• 35 ft• Bentonite Pour
Monitoring ❑Recovery -
Injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 35 ft. 57 ft• Sand
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
0 Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) ❑Tracer FROM TO , DESCRIPTION(color,hardness,soilrock type,grain size,etc.)
O Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. 0•5 ft. Topsoil
04/06/2023 MW-3 0.5 ft• 10 ft. Silt
4.Date Well(s)Completed: Well Bo •
10 ft. 57 ft. Weathered rock
5a.Well Location: ft. ft.
Carolina Composting n/a ft. ft. •
Facility/Owner Name Facility ID#(if applicable) ft. ft. ( ' `'+ `
6483 Highway 109 North, Wadesboro, NC ft. ft. •
Physical Address,City,and Zip 21.REMARKS ,1 l J I Ei 7 1 it i 3
Anson 6496-0048-3734
County Parcel Identification No.(PIN) lit;,...,.....:...,, '•'�'"' i'I''i
C!'1%}ri :NI)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one 1at/long is sufficient) '•
35.035139 N 80.019896 W 4/25/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑�Permanent or OTemporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with 15A 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 ONo 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: 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: 57 (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'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 rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: rY 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&Injections 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