GW1--00443_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD(GW-11 ' .For Internal Use Only:
1.Well Contractor Information:
Daniel Summers '
14.WATER ZONES .
Well Contractor Name FROM TO DESCRIPTION - -
20 ft.. . 35 ft.
2579-A • ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) •
Carolina'Soil Investigations,'LLC FROM. . • DIAMETER . THICKNESS .'• MATERIAL . .
• 0 ft. . 20 ft.... 2 , in, sch 40' .pvc .
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) -
2.Well Construction Permit#: WM030.1322/Gaston#20995 • FROM TO DIAMETER . 'THICKNESS ' MATERIAL
List all applicable well construction permits'(i.e.UIC,County,State,Variance,etc) ft. . ft. . in:
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3.Well Use(check-well use): • ft. ft. , in..
Water Supply Well: 17.SCREEN
FROM TO DIAMETER- SLOT SIZE - THICKNESS. MATERIAL
- El Agricultural l]Municipal/Public : : 20 ft. . -35 ft, - 2 in. 010 sch 40. pvC -
®Geothermal'(Heatitig/Cooling Supply) 0•• Residential Water Supply(single) . ft '. fL in.:''..
. Q'Industrial/Commercial 0 Residential Water Supply(shared) - - - -
.0Irrigation 18.GROUT
.0 Wells?100,000 GPD - ,' FROM . .TO :•MATERIAL EMPLACEMENT METHOD&AMOUNT.
Non-Water Supply Well: .. 0. ft.... 5 ft- portland mix&Pour- -
E Monitoring .LIRecovery 5 'fa 18 ft bentonite tremie
•Injection Well: - ft.. ' ft. '
•0 Aquifer Recharge 0,Groundwater Rernediation -
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery .0 Salinity Barrier .FROM." . .TO ' MATERIAL . EMPLACEMENT METHOD .
o Aquifer Test 'El Stormwater Drainage 18 it • 35 ft-• . 10/30 silica sand tremie :
.j Experimental Technology -El Subsidence Control ft._ ft. •
D,Geothermal(Closed Loop) . El Tracer ' 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO .DESCRIPTION(color,hardness,soil/rock type,groin size,etc.)
71 Geothermal(Heating/Cooling Return) '0 Other(explain under#21 Remarks) .
112223 0 ft.: - ,35 ft.. brown silt loam/brown silty.clay/saprolite
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' 4.Date Well(s)Completed: Well ID# MW-4 ft. fL '
5a.WellLocation: • • fL ft..
Mountain Village Pantry ft.. rt. •
'''1:::aII i P n
Facility/Owner Name Facility ID#(if applicable) e u m, a.�L.'s,. ft: ft.
• 2302 Dallas-Chierryville Hwy Dallas, NC - • • ft., ft. JAN 1 6 2024
Physical Address,City,and Zip - - - . - .•
ft. ft.
Gaston . , 1in f-n �- � � .:�T;,r-t_h
21.REMARKS r{71,
County Parcel Identification No.(PIN) 'ry" L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: : •
(if well field,one lat/long is sufficient) . 22.Certification: - -
35.32003 - N -81.21770 • . W - ..i�J- 9 ____--
II 11-22-23 •
6.Is(are)the well(s):X�Permanent or 0 Temporary Signature of Certified Well Contractor• ' Date
7.Is this a repair to an existingwell: Yes or X No By signing this-orm,I hereby certify that the well(s)was(were)constructed in accordance
p -.0 0 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-I 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: 35 • (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100')' 24a. For.All Wells: Submit this form•within 30 days of completion of well
construction.to the following:
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10.-Static water level below top of casing: . 29 (ft.) Division of Water Resources,Information ProcessingUnit,
If water level is above casing,use"+"
• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8" (in.)
24b.For Iniection 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:
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&Iniection 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.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018.