GW1--05131_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Virgil Wilson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 4.0 IL 1 5 ft• Wet
4473 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DI\METER THICKNESS I MATERIAL
Parratt-Wolff, Inc. ft. tt. in. l
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft• 2 i"• sch40 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 5 R. 15 ft. 2 i"' .010 sch40 pvc
F. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)0 Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROST TO NIATERIAt. EMPLACEMENT METHOD& %MOUNT
❑Irrigation 1 ft• 3 ft• Bentonite Chi Tremie
Non-Water Supply Well:
ft. ft.
lMonitoring ❑Recovery
Injection Well: ft. ft.
0 Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 3 rt. 15 ft• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION icolur.hardness.soil;rock rope,grain'ire.etc.]
OGeothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) ft. ft.
7-25-23 Well ID# MW 12 ft. ft. _ _
4.Date Well(s)Completed:
ft. ft. `�/ _?
5a.Well Location: V i Vt
ft. ft.
Silverline Plastics ft. ft. AUG 1 8 ?on
Facility/Owner Name Facility ID#(if applicable] ft. ft.
Ifl Qnrabt fl ?roc «M 11t
950 Riverside Drive, Woodfin 28804 ft. ft. l3OC
Physical Address,City.and Zip 21.REMARKS
Buncombe 973061233700000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. ification:
(dwell field.one lat/long is sufficient)
35.625140 N -82.579991 W 1 (\ vi �� � g• 4, a3
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or CTcmporary By signing this form.I hereby certify that the well(s)wns(were)constructed in accordance
with ISA NCAC 02C.0100 or 1 SA NCAC OK.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or sNo copy of this record has been provided to the well owner.
If this is a repair,Jill 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: 15 (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: 4'0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
111.Borehole diameter: 8 1/4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Air knife to 5'; HSA w/5' macro core 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
li.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