GW1--00568_Well Construction - GW1_20240118

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: `
Matt Steele a'14.WATERZONES. ` ` '- ._
FROM _ TO DESCRIPTION
Well Contractor Name ft. ft.
4548 A ft. ft. -
NC Well Contractor Certification Number !`_15.OUTER CASING(for multi-cased*ells)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-loop)
2.Well Construction Permit#: N/A 0
FROM _ TO DIAMETER THICKNESS MATERIAL
ft. 30 ft• 4" : in• sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) - -
ft. ft. i in.
3.Well Use(check well use): ?=17.SCREEN -:r °°`. `''�v"
Water Supply Well: FROM _ TO DIAMETER l SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30 ft. 50 ft. 4 in.' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ls.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 26 ft. Grout pour
Non-Water Supply Well:
l7Monitoring P 4. y '., �gl r-tc�q�er}�l"'-° • 26 ft• 28 ft• Bentonite pour
�
Injection Well: ft. ft.
❑Aquifer Recharge J A N 1 87192 1water Remediation 19.SAND/GRAVEL,PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test 111t3 ne4iCa r rc ^•r' ''!! 28 ft. 50 ft. Sand
[5((���tbYinWaTE��rainage
' ❑Experimental Technology D�'C'`usubsidenceControl ft. ft.
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. Gravel
4.Date Well(s)Completed: 01/04/24Well ID#RW-1 0.5 ft. 8 ft. Brown silt
8 ft. 15 ft. Tan silt
5a.Well Location: 15 ft. 17 ft. : Grey/green weathered rock
Highway Mobil 00-0-000012512 17 ft- 36 ft• ITan mudstone
Facility/Owner Name Facility ID#(if applicable)
170 Evans Road Thomasville NC 27360 36 ft• 40 ft, brown silt to coarse sand
r ' 40 tt• 50 tt• Tan mudstone
Physical Address,City,and Zip .. '
Y Y `�31.REMARKS :� _ t.
Davidson 16-331-0-000-0006
County Parcel Identification No.(PIN)
•
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: „.7� rcati
(if well field,one lat/long is sufficient) r"
35.872186 N 80.157027 �,, .% = 01/08/24
Signature of Certified Well Contractor Date
6.Is(are)the well(s): l7Permanent 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 ENo 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 same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 7.0 (in.) 24b. For Injection Wells ONLY:) In 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 enter,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this foam 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