GW1--02897_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
Alan Michael Sturchio 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. Dry
4570-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Froehling & Robertson FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop).
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.) +2.7 ft. 9.8 ft. 2 in* Sch.40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM ; TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 9.8 ft. 19.8 ft. 2 in. 0.10 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT '
❑Irrigation FRM _O TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: +0.4 ft. 0.0 ft. Concrete Pad
x(Monitoring ❑Recovery - 0.0 ft. 5.8 ft. Neat cement - Placement-- - --
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 5.8 ft. 7.a ft. eentonite Gravity
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 7.8 ft. 19.8 ft. #2 Well Gravel Gravity
❑Experimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
Hard,Triassic Soil
4.Date Well(s)Completed: 4-10-2024 Well ID# B-51 ft. ft.
5a.Well Location: ft. ft.
Jordan Lake Greenfield WTP ft. ft. :- •..7, , ,,-,
Facility/Owner Name Facility ID#(if applicable)
ft. ft. ,v,. �_, .i +1 j._.Li
1855 N. Pea Ridge Road, Pittsboro, NC 27312 ft. ft. MAY 1 !► 2024
•
ft. ft.
Physical Address,City,and Zip
Chatham 21.REMARKS ir:s(
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --
(if well field,one lat/long is sufficient) 22.Certification:
35.7159611 N -79.060925 �, 1
. -3 -2y
6.Is(are)the well(s)JPermanent or ❑Temporary Signature of Certifie Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or DiNo 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 has been provided to the well owner.
repair under#21 remarks section or on the back of this font.
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: 19.8 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 r@r 100') construction to the following:
10.Static water level below top of casing: Dry (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
Auger above, also submit one 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
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 Ito 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