GW1--04395_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 iicable)
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. i in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
• FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 12 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 12 ft 32 ft• 2 i°' 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. 8 ft• Grout _Pour
Non-Water Supply Well: 8 ft. 10 ft. Bentonite Pour
laMonitoring ❑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
10 ft• 32 ft. Sand
DAquifer Test 0 Stormwater Drainage -
ft. ft.
0 Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 _ft. '_0.5 ft. Topsoil
04/06/2023 MW-4 0.5 ft• 6 ft. Silt •
4.Date Well(s)Completed: Well ED#
6 ft. 32 ft. Silt with weathered rock
5a.Well Location: ft. ft.
Carolina Composting n/a ft. ' ft. a 7- ..,,, •t. ,7,
.&....6 l a P._.,rt
Facility/Owner Name Facility ID#(if applicable) ft. ft. "' &.„..a l'� i
6483 Highway 109 North, Wadesboro, NC JULft. . ft. 0 7 2023
Physical Address,City,and Zip 21.REMARKS
Anson 6496-0048-3734 lnic.,i.::rr.n r'F ,,g Lin
DW'; ;•.:r=-i:
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)
35.035139 N 80.019896 W 4/25/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby certify 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 forrn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 32 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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�/ 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: '7 construction to the following:
(Le.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
24c.For Water Supply&Injection!Wells:
13a.Yield(gpm) 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources. Revised August 2013