GW1--00569_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells '
1.Well Contractor Information: ,
Matt Steele 14.WATERZONES
FROM TO _ DESCRIPTION
Well Contractor Name ft. ft. 1 '
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. ;
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: nia 0 ft, 20 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): I7.SCREEN
--
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 20 ft. 50 ft. 2 in'. 0.010 sch 40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commerc'al. . �'aeSiif ntial Water Supply(shared)
18.GROUT
FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hrigation 'a ..•°'R-•�-+"'' b�+ ft. ft
Non-Water Supply Well: 0 16 Grout pour
©Monitoring JAN 1 S ZODRecovery 16 ft. 18 ft. Bentonite pour
Injection Well: UB ft. ft.
x-..-r��ir it fir �,:fi.:�,17
❑Aquifer Recharge 111f3 t'""` . w.G❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
��°�''t FROM _ TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 18 ft. 50 ft. Sand
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary).'
OGeothermal(Closed Loop) ID Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.5 ft. Gravel
01/03/2023 MW-26 0.5 ft. 8 ft. Orange clay
4.Date Well(s)Completed: Well ID#
8 ft. 25 ft. Weathered mudstone
5a.Well Location: 25 ft. 45 ft. Dark brown mudstone
Highway Mobil 00-0-0000012512 'ft ft.
45 50 Brown silt to coarse sand
Facility/Owner Name Facility ID#(if applicable) -- -, --
ft. ft.
170 Evans Rd, Thomasville, NC 27360 ft. ft.
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: 1-."Cr fcati
(if well field,one lat/lopg is sufficient)
35.872186 N 80.157027 w - _ 01/08/24
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby cert fy 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 El 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#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 if different(example-3@200'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
1
11.Borehole diameter: 4.5 (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
(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:
13a.Yield(gpm) 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 h e al'th department of the county where
constructed. 1
Form GW-I - North Carolina Department of Environment and Natural Resources-Division of Water i esources Revised August 2013