GW1--01417_Well Construction - GW1_20240301

. 1 • Print Form •
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: '
1.Well Contractor Information: . . . .
•
Daniel SUnlnlers •14..WATERZONES'
• Well Contractor Name FROM .TO DESCRIPTION
8 ft. 23 ft
2579-A -
ft. ft.. .
NC Well Contractor Certification Number •
• 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Carolina Soil Investigations,'LLC FROM. TO DIAMETER'.. THICKNESS . • MATERIAL
0 ft. . . 8, ft' • 2 I in. sch 40 pvC
Company Name •
• -16.INNER CASING OR TUBING(geothermal closed-loop)
DEQ: WM0301342. FROM TO . ' -DIAMETER . 'THICKNESS •MATERIAL •
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) • ft.:: ft. in, .
• 3.Well Use(check well use): 1t {t in
.. • Water Supply Well: •
17.SCREEN.
FROM' _ _ TO • DIAMETER SLOT SIZE • THICKNESS. . MATERIAL
Q Agricultural EDMunicipal/Publio . 8 rt. 23-ft:. 2 in? ' 010 • sch 40 , pvC
• •O Geothermal(Heatirig/Cooling Supply)• •0 Residential Water Supply(single) . ft • ft.
ht.,
. 0 Industrial/Commercial 0 Residential Water Supply(shared) . 18-GROUT
0 Irrigation. . _El Wells?100,000 GPD .• FROM . .TO . :'MATERIAL EMPLACEMENT METHOD&AMOUNT:
' Non-Water Supply Well: . 0 ft: .4 ft poitlan'd mix&.Pour.
Q Monitoring. Recovery 4 fa" 6 ft:- bentonite. tremie
•Injection Well: ft.. ft
0 Aquifer Recharge , ' .GroundwaterRemediation =
• '19.SAND/GRAVEL PACK(if applicable)
,['AquifeI Storage and Recovery .0 Salinity Barrier .FROM. . .TO .- ' MATERIAL- ." EMPLACEMENT.METHOD •
OAquifer Test El:StormwaterDrainage • • 6 ft- '23- ft_. 10/30,silica sand tremie
• D Experimental Technology ®Subsidence Control ft.. ft. . :
.Geothermal(Closed Loop) . •Tracer 20.DRILLING LOG(attach additional sheets if necessary) . • •
Geothermal Heatin Coolin Return Other ex lain under#21 Remarks FROM TO DESCRIPTION(color,Hardness,soil/rock type,grain su e,etc.)
( g ) ( p ) 0 ft 23 ft. brown silt loam/brown silty clay/saprolite
4.Date Well(s)Completed:02-14-24 Well ID#• MW-� ft. . ft', ,
5a.Well Location: ft• ft: l' .p-• ." • 17-
Pilot ft " ft . , rs� 1�C 1 i if i
Facility/Owner Name Facility ID#(if applicable) ft: . ft' - MAR
0 1 9074
2700 Chamber Dr Monroe, NC . ft.- . ft. -
Physical Address,City,and Zip ;; p;; Um,
ft. ft t1nthIi'xi.,t?:..
Union . . rmir,si
. • . • • • . . 21.REMARKS - . .
County Parcel Identification No.(PIN) I.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hit/long is-sufficient) 22.Cerhtiication:
35.05130 N -80.62312 w • nn
X -- 02-14-24
•
6..Is(are)the well(s):X®Permanent or inTemporary Signature of Certified-Well Contractor! Date
7.Is this a repair,to an existing well:. Yes or No By signing this form,I hereby certp'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
If this is a repair,fill out known well construction information and explain the nature of the copy of this record hds 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 1 GW-1 is needed.Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary.
drilled: . . 1 •
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: . 23' (ft.)
For multiple wells list all depths ifdierent(example-3@200'and 2@Ioo')' 24a. For.All Wells:-Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 12 (ft.) Division-of Water Resources,Information ProcessingUnit,
If water level is above casing,use"+"
$„ 1617 Mail ServicelCenter,Raleigh,NC 27699-1617 •
11..Borehole diameter: (in.) j i; •
24b.For Infection Wells:In addition to sending the form to the address in 24a •
12.Well construction method: auger above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program;
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service1 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: -24c.-For Water Supply&Infection 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 countyy health department of the county
' where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division ofWater•Resources Revised 6-6-2018.