GW1--00939_Well Construction - GW1_20240209

Print Form;:
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Terry White '14.WATER ZONES- .;T 'J. .. :.,
Well Contractor Name FROM TO DESCRIPTION
ft ft. I '
3287-A ft ft I
NC Well Contractor Certification Number 15.OUTER:CASING(for multi-cased wells)OR LINER(if ap licable)
IET FROM TO DIAMETER' THICKNESS MATERIAL
ft ft. in.
Company Name
Wn/�0 O /I Q/1 16.INNER CASING ORTUBING(geothermal closed-loop)".=-`- : . - -
2.Well Construction Permit#: IYI 'T -T�/'T FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) 0 K. 15.2 ft 2 (IL Sch40 PVC
3.WellUse(check well use): ft fa i in.
Water Supply Well: 17'SCREEN e.x , " s `. _'.::.,'_ •"
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 15.2 ft 30.2 K. 2 in•! '0.010 Sch40 PVC
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) f. ft. iai
Industrial/Commercial OResidential Water Supply(shared)
`18.GROUT ,
Irrigation - -- ---~ - -- - - - - ------- -FROM-- TO - - MATERIAL - .EMPLACEMENT METHOD&AMOUNT- -- -
Non-Water Supply Well: 3 ft 13 ft Bentonite Poured/250LB
x Monitoring 0Recovery 0 K. 3 ft Cement Poured/45LB
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL-PACK(if applicable)' "'
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD'
Aquifer Test 0Stormwater Drainage 13 ft 30.5 K' #2 Sand Poured
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer -20.DRILLING LOG(attach additional'sheets if necessary). u
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Another(explain under#21 Remarks)
1/22/2024 MW 12 ft See Consultant Log
4.Date Well(s)Completed: Well ID#
5a.WellLocation: ft. ft
Monticello Oil ft. ft.
Lo'h-\ �D
Facility/Owner Name Facility ID#(if applicable) ft. ft. � k'�; , /�
8005 Benaja Rd. Browns Summit, 27214 ft. ft. Y
Physical Address,City,and Zip ft ft FEB 102
4
Guildford ;it.REMARKS
Inrorira m cDrc et- Ursit
County Parcel Identification No.(PIN) 0W0JOf3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.223508 N 79.677635 W �`; 1/26/2024
6.Is(are)the well(s)t3Permanent or OTemporary Signature of Cettifie ell Contractor Date
-
By signing this form,I hereby certibr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or 0No with 1SA 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:one SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30.5 ft
P ( ) 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:23.8 (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:8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Augerabove,also submit one copy of this Ifocm 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
13a.Yield(gpm) Method of test. 24c.For Water Supply&Injection 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016