GW1--04396_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.
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 MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
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,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 20 ft• 40 ft• 2 in' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 16 ft• Grout Pour
Non-Water Supply Well:
l7Monitoring ❑Recovery 16 it 18 ft• Bentonite Pour
Injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier
18 it. 40 ft. Sand
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) OTracer FROM , TO. DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 0.5 ft Topsoil
04/06/2023 MW-2 0.5 it 12 ft. Silt
4.Date Well(s)Completed: Well ID# '
12 .ft• 36 ft. Weathered rock
5a.Well Location: 36 ft• 40 ft. , Fractured rock with water
Carolina Composting n/a ft. ft. .
Facility/Owner Name Facility ID#(if applicable) - '
ft. ft.
6483 Highway 109 North, Wadesboro, NC
9 7 ft. ft. ( °t:.n 7. r-'�h
Physical Address,City,and Zip ry s�� t •ys-1 •
21.REMARKS
Anson 6496-0048-3734 JIII 0 7 71173
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: i� In c' t'.^`�'l '"`'''"'''""j ''%
(if well field,one lat/long is sufficient) 22.Certification. f /� V Q';3 O;.
35.035139 N 80.019896 W 4/25/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ElPermanent or El 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 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 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:40 (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
,
24c.For Water Supply&Injection1Wells:
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