GW1--04041_Well Construction - GW1_20240708

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: "7"
1.Well Contractor Information:
Ronald F. Barron 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. Unconsolidated
2091-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Piedmont Industrial Services FROM TO DIAMETER THICKNESS MATERIAL
0 ft 20 ft 2 in. Sch 40 PVC
Company Name
W M 0100579 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.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM _ TO _ DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public 20 ft 35 IL 2 III' .010 Sch 40 Pvc
Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. - ft - in.
Industrial/Commercial 0 Residential Water Supply(shared)
10.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 15 ft Concrete Poured
X Monitoring 0Recovery 15 ft 17 ft. WSB.ntonnechpo Poured
Injection Well:
ft ft
Aquifer Recharge 0 Groundwater Remediation -
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage 17 ft 35 ft- Filter sand Poured
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) IDTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness eolUrock type grata size etc.)
0 ft- 1 ft Gravel
4.Date Well(s)Completed:6-4-24 Well 1D#MiW-12 1 ft. 16 ft Bm Blk Silty Clay
ft White Tan 35 ft' ^
t"-
5a.
Well Location: to silty sand YR t. .
f . E
DAHH Ventures LLC c/o David Hamby NCDEQ Incident#13052 ft . % `•.t.:! V
Facility/Owner Name Facility ID#(if applicable) ft ft. J U L U A ?024
503 Creekway Drive ft ft
Physical Address,City,and Zip
ft. f. It kJ: ,a . ',-,- ;..�,
C 21.REMARKS I?'}:C.,$t.v
Caldwell
iQ3-izs'a y
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:
-- el. ,?2-- -3 ` c/�/r/ W - :�- ea'sz-71 Z Y
6.Is(are)the well(s)ix Permanent or Temporary Signature of Certified 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: IDYes or XON° with 15A NCAC 02C.0100 or 1SA 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:"" SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 37.5'
P (ft) 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:
10.Static water level below top21.96
of casing: (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: 6 (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.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