GW1--02933_Well Construction - GW1_20240513

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Adam Santry :14.WATER ZONES '
FROM TO DESCRIPTION
Well Contractor Name I
NCWC 4526-A f` ft n/a-Closed Loop Geo
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Allied Well Drilling FROM TO DIAMETER. THICKNESS MATERIAL
ft. ft. •
; An. n/a-Closed Loop Geo
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W 10300500 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in. n/a-Closed Loop Geo
3.Well Use(check well use): ft. ft. in.
Water Supply Well: '.17.SCREEN
pp y FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.' n/a-CLG
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM - TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 500 ft 0 ft Bentonite via tremie pumped from bottom
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge 0Groundwater Remediation
G.19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft n/a-Closed Loop Geo
❑Experimental Technology ❑Subsidence Control ft. ft. I -
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type grain she,etc.)
0 ft 10 ft brown dirt
4.Date Well(s)Completed: 4/12/?4 • 'Well ID# 10 ft 30 1 ft brown silty soil ' `"° ".-k. ,, �,/ C..c '.
tom . L.
5a.Well'Locatiou: • - • , 30 ft 58, .- ft' . brown weathered rock , A
UCPS - East Elementary 58 ft 84 ft soft to medium gray rock MA(( LGZ.
Facility/Owner Name Facility ID#(if applicable) 84, .500 ft medium gray rock if x.",r;i?::•' + -
515 Elizabeth Ave, Monroe, NC 28112 ft. ft. t;j``�" �"'
Physical Address,City,and Zip ft. ft. ,
Union 09195138 ,'21.REMARKS '
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.CerttiQfincation: I c /
450593.2787 1541268.3494 �, av � J
N l 7l 4i
- • 6.Is(are)the well(s): L'JPermanent or ❑Temporary Signature of Cemfied Well Contractor _ _ _ - Date
By signing this form,I hereby certiry that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or C1No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:6e 24.SUBMITTAL INSTRUCTIONS
500 ,
9.Total well depth below land surface: (ft)• Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths'if dtfferent(example-3@200'and 2@100)
n/a . • 24a. For All Wells: Original form.to,Division of Water Resources (DWR),
10.Static water level below top.of casing: (ft) 'Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use,"+" + ,
11.Borehole diameter: 5.75 (in.) 24b.For Injection Wells:Copy to DWR;Underground-Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air-rotary • . -
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) _. county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: •24d.For Water Wells producing!over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: ,
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource' Revised 6-6-2018