WI0300495_Well Construction Record(s) (GW-1)_20231017

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Wesley J. Sorrells 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3577
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Terraquest Environmental Consultants FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eother al closed-loo
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): Ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural [:)Municipal/Public 44 ft' 49 ft- 1 in. 10Slot SchdAC PVC
Geothermal(Heating/Cooling Supply) [3Residential Water Supply(single) ft. ft. in.
hidustrial/Commercial Residential Water Supply(shared) 18.GROUT
hTijzation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.5 ft 40 ft Portland Pour
X Monitoring ORecovery 40 ff 42 ft- Bentonite Pour
Injection Well:
ft. ft.
Aquifer Recharge QlGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 01 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3StormwaterDrainage 42 ft. 49 ft. No. 2 Sand Pour
Experimental Technology 01 Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
0 ft• 0.5 ft• Asphalt
4.Date Well(s)Completed: 10/10/23 Well ID#AS 1 0 5 ft• 1 ft Gravel
5a.Well Location: 1 ft 14 ft Clav with some silt
Little Market Basket 14 ft 49 ft Silt with very little clay
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
3541 Talylorsville Hwy. Statesville NC
Physical Address,City,and Zip
ft. ft.
red e I l 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certifies'on:
35.809841 N -80.948711
10/17/23
6.Is(are)the well(s)�IX Permanent or [3Temporary Signature of Certified ell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or XONo with 15A NCAC 02C.0100 or 15A 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: 49 (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,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Solid Stem Auger above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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: 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 of Water Resources Revised 2-22-2016