GW1--06643_Well Construction - GW1_20231006

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WELL CONSTRUCTION RECORD(GW-1't For Internal Use Only: '
1.Well Contractor Information: 1
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Daniei S-ummers 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
• 30 ft. 45 ft.
2579-A ft. ft. . I ,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Carolina Soil Investigations, LLC / FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 25 ft. 2 in- sch 40 pvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
NCDEQ:WM0301308 Gaston CO:20995
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits•(i.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): it ft in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Q Agricultural El Municipal/Public 25 ft. 45 ft 2 in' 010 sch 40 pvc
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) it ft. in,
©Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
•
0 Irrigation 0 Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 5 ft• portland mix&Pour
Q Monitoring 0 Recovery5 ft 23 ft bentonite tremie
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
OAquiferStorageandRecovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage 23 ft- 45 ft. 10/30 silica sand tremie
©Experimental Technology 0 Subsidence Control ft. ft.
0 Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
'1 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/roek type grain tine etc.)
08 3123 0 ft- 45 ft- brown silt loam/brown silty clay/saprolite
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4.Date Well(s)Completed: Well ID# MW-1 ft. ft.
5a.Well Location: ft. ft .t s= ,.t .r,p,
Former Mountain Village Pantry , ft. ft t t. ..%.'s I+.--r w: h...:..,•
Facility/Owner Name Facility ID#(ifapplicable) ft. ft �•
2302 Dallas Cherryville Hwy Dallas, NC ft ft. fl( T �f173
Physical Address,City,and Zip -:
ft ft Ifli I+rth:;:i t c' d1/ :'. ti}e
Gaston r>,:�:;-t.?,z1
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.32013 N -81.21754 W i)c,-- 2 l(L
08-31-23
6.Is(are)the wll(s):X®Permanent or 0 Temporary Signature of Certified Well Contractor Date
7.Is this a repair to an existing well: Yes or No By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed.Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary.
drilled: 1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 45 (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 38 (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: (in.)
24b.For Injection Wells:In addition to sending the form to the address in 24a
12.Well construction method: auger •
above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
• 13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division ofWater Resources' Revised 6-6-2018