GW1--00563_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells " i
1.Well Contractor Information:
Matt Steele • 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. {
4548 A ft. ft. I
NC Well Contractor Certification Number 15.OUTER,CASING(for multi cased wells)OR LINER(if ap licable) . ,.;x. " ,
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. 1 I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) `
WM0401488FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 30 ft, 2 I in' sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 1,7.SCREEN-. ' ' ' ''' ' ''''
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30 ft. 70 ft. 2 in'' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.;
❑Industrial/Commercial 18.GROUT__
a,Y x 1213esi¢ential Water Supply(shared)
v�'^. }'m".—1 ,9 r�'1 Vv FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ,, : ,, ',,;i; CC\777 1 0 ft' 26 ft, Grout our
Non-Water Supply Well: M p '
ElMonitoring .IAjV 1 S VARecovery 26 ft. 28 ft, Bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge .7rr ,,DG ),
:D r ❑GroundwaterRemediation .19:SAND/GRAVEL�PACK(if applicablc= -'-• - . = f
ti\' l i--ij � FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovet}I ❑Salinity Barrier 28 ft. 70 ft. Sand
❑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(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft, 0.5 ft. Topsoil •
01/04/2023 MW-24 0.5 ft• 5 ft. • Dark brown clay
4.Date Well(s)Completed: Well ID# 5 ft. 38 ft. Tan mudstone
5a.Well Location: 38 ft, 42 ft. Brown silt
Highway Mobil 00-0-0000012512 ft ft.
42 64 + Tan mudstone
Facility/Owner Name Facility 1Db(if applicable) 64 ft, 68 ft. Brown silt to coarse sand
170 Evans Rd, Thomasville, NC 27360 68 ft. 70 ft. Tan mudstone
Physical Address,City,and Zip
21.REMARKS '� _ - `
Davidson 16-331-0-000-0006
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 77:6'7'j?
Ce sati
(if well field,one lat/long is sufficient) z..+*'' .+
35.872186 N 80.157027 �,� 01/08/24
Signature of Certified Well Contractor Date
6.Is(are)"the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or ©No 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 1121 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 seine construction,you can
submit one form. SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface: 70 (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@I00) construction to the following: 1
10.Static water level below top of casing: n/a (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:4•5 (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: air hammer 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
) 24c.For Water Supply&Injection Wells:
(gpm)
Yield Method of test: 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