GW1--02065_Well Construction - GW1_20240405

WELL CONSTRUCTION RECORD For Internal Use ONLY:This form can be used for single or multiple wells
1.Well Contractor Information: i
Joshua N. Robertson 14MATERZONES 8:.. _: _..i._ - y.. _..._ .:.
FROM TO DESCRIPTION
Well Contractor Name ft ft I ' .25GPM@ below 200'
2461-A ft ft 1
f3&OUTER'OASINCOOkiiiiiitkasedfivFlli)10R33NER(ifaP cable},.-
NC Well Contractor Certification Number ?• _'
FROM TO DIAMETER THICKNESS - MATERIAL
Triad Drillers, Inc. o ' ft ft. . 11 in.
Company Name i 16:<INNER CASING ORYIIBING'(gtliermallosed-Ioop) ,:_:x- '_ . .t;
WIO60O246 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: ft ft (n.
List all applicable well permits(i.e.Counry,State.Variance,Injection,etc.) '
ft $ • 1 m
3.Well Use(check well use): L7:=SCREEN.._w j_r..., _: .A,x : . t e ?
Water Supply Well: FROM TO DIAMETER , SLOT SIB THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. io:
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in'
S GRO
❑lndustriaUCommercial ' ❑Residential Water Supply(shared) =TiIT_ _ :__. .,�y. .._. ... ,. _... k. .=1
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 f4 300 ft Thermal Pump
Non-Water Supply Well: ft ft
iJMonitoring ❑Recovery -__ - Grout - - --- -- - — . --- --- -
Injection Well: ft ft.
❑Aquifer Recharge ❑GroundwaterRemediation :19 SAND/GRAVEL'L'ACS'(itapplice6le). -_Y= EMPLACEMENT
❑Aquifer Storage and Recovery ❑Salinity Barrier •
FROM TO MATERIAL EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. +
DExperimental Technology OSubsidence Control
2ODRIELINGLOG(attach`addrhonelsll etsifnecessary) " ~
rGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIP'rION(cutor, nan,soil/inek type.grain use,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 5 ft j ' Clay
4.Date Well(s)Completed: 03/25/24 Well ID# "5 ft. 93 ft i. Sand
93 ft 300 n ,„,!,..7.m-- : ;Granite
5a.Well Location: ft ft. ; i"4 .'(:..a it-..% aft ''.::U:-:,
Bowman Mechanical RDU,LLC
ft. ft s r
Facility/Owner Name Facility ID#(if applicable) APR 6 L4
ft f. i '
473 Fred Burns Rd, Holly Springs ft ft lnr�;r r.,,,,:-ry ;, 4:;,-}, u
' DINCV:at10,
Physical Address,City,and Zip g2IME11fARKSf r:` - I,A ,..s`' _F _ _ .:... ._ 3
Harnett 0600246 1 ,
County Parcel Identification No.(PIN) I :
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: i •
•
("dwell field,one lationg is sufficient) 22.Ce "!cation:
N w A A aOl' 03/28/2024
Signature Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
- - 7.Is this a repair to an existing well: -❑Yes or aN0- -- - -copy ofthis record has been-pi-wide- to the well owner.
If this is a repair,fill out brown 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: 2 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the sante construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 300 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2ca100) construction to the following:
10.Static water level below top of casing: 70 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above caring,use"+" 1617,Mail Service Ce;ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) • 24b.For Infection Wells ONLY: In addition to sending the form to the address in
24a above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following: j
(ie.auger,rotary,cable,drectpush,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,ter,Raleigh,NC 27699-1636
.25 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test Also submit one copy of this for*within 30 days of completion of
13b.Disinfection type: HTH Amount 16 oz. , 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