GW1--00564_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. ' 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. 1 in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-look'.
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: n/a 0 ft. 13. ft. 2 , 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): 17.SCREEN
Water Supply Well: FROM TO . DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 13 ft. 43 f=• 2 '"; 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑beside tial Water Supply(single) ft. ft. in.
18❑Industrial/Commercial. ' -(',ter l' R t , I esldeD ial Water Supply(shared)1- FROMROUT_ TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT_
❑Irrigation 0 ft 9 ft. Grout pour
Non-Water Supply Well: J R'v 1 S •tOL4
17Monitoring ❑Recover n 9 f=• 11 f= Bentonite pour
Injection Well: -,r.7;�,�=�ti '•," s ft. ft.
Y_"-1, V S �f
❑Aquifer Recharge C�m t�'���iroundwater Remediation 19.SAND/GRAVEL+PACK(if applicable) >,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 11 f= 43 ft. Sand
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
['Experimental Technology ❑Subsidence Control $0.'DRiLLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO' DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothetmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f=• 0.5 ft. Topsoil
01/02/2023 MW-25 0.5 ft. 4 ft. , Brown silt to coarse sand
4.Date Well(s)Completed: Well m#
4 ft. 7 ft. Dark grey to silt to coarse sand
5a.Well Location: 7 ft. 13 ft. Grey mudstone
Highway Mobil 00-0-0000012512 13 f 18 ft. Tan mudstone
Facility/Owner Name Facility ID#(if applicable)
170 Evans Rd Thomasville NC 27360 18 f 33 f= Grey granite
' t 33 ft. 43 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: 2 C�ficati
(if well field,one lat/long is sufficient) ,✓
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 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or lNo 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#21 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 scone construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:43 (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 a 00'and 2@100') construction to the following: I
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: lIn addition to sending the form to the address in
air hammer 24a above, also submit a 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
(gpm) 24c.For Water Supply&Injection)Wells:
m 13a.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