GW1--05132_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.M.ell Contractor Information:
14.WATER ZONES
Virgil Wilson
FROM TO DESCRIPTION
Well Contractor Name 7.5 ft. 19 fL Wet
4473 ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, 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. 9 ft. 2 in. 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 9 ft. 19 ft. 2 1° 010 sch40 pvc
['Geothermal(Heating/Cooling Supply) ❑Residential Waters I (single) ft. f►• in.
� g PP y) Supply
❑Industrial/Commercial ['Residential Water Supply(shared) I8,GROUT
FROM TO MATERIAL EMPLACEMENT NIF.THOD&',MOUNT
❑Irrigation 1 «• 5 ft• Portland Cem Tremie
Non-Water Supply Well:
mMonitoring ❑Recovery 5 ft. 7 ft• Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. e.
720 #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ['Tracer FROM TO DESCRIPTION(color.hardness,soil/rock type•grain size.etc.)
❑Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) ft. ft.
ft. ft. ( .... .... . -e..
4.Date Well(s)Completed: 7-27-23 Well ID# M W 13 ft.ft. ! + V L,
E
5a.Well Location: ft. ft.Silverline Plastics AUGHVU $ 202
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. jfllvfA, n r'r^C.se<nq Un1i
950 Riverside Drive, Woodfin 28804c_v3s.X.;
ft. ft.
Physical Address,City.and Zip 21.REMARKS
Buncombe 973061233700000 8" FMC in black top
(•Dungy Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.(ertification:
(if well field one lat/long is sufficient)
35.622838 V N -82.577873 W l & W l 0 d
s -
Signature of Certified Well Contractor Date
6. Is(are)the well(s): ©Permanent or ❑Temporary By signing this form.I hereby certify that the wells)wms(were)constructed in accordance
with 15A NCAC 02C.01011 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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#2/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: 19 (I1.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 tr 00'and 2@l00') construction to the following:
10.Static water level below top of casing: 7.5 (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: 8 1/4 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: HSA 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 G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013