GW1--04042_Well Construction - GW1_20240708

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: IM1171•11
1.Well Contractor Information:
Ronald F. Barron 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
ft. f- unansdueied
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. 17 ft. 2 in. Sch 4o PVC
Company Name
WM 0100579 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
-
List all applicable well construction permits(i.e.NC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): rt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 17 ft. 32 ft. 2 in. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft, in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO ' MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 14 ft. Concrete Poured
x Monitoring DRecovery 11 ft. 14 ft• 3/8awtoniachips Poured
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK Cif applicable)
Aquifer Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
Aquifer Test f__f Stormwater Drainage 14 ft. 32 ft. Filter sand Poured
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) [J 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)
0 ft. 1 ft Gravel
4.Date Well(s)Completed:6-4-24 Well W#M W-13 1 ft• 16 h Bm BIk Silty Clay
5a.Well Location: ,s ft. 32 ft. White Tan silty sand PWR
DAHH Ventures LLC do David Hamby NCDEQ Incident#13052 ',- '°Y J I
ft it F; Li Le.a 'L.:
Facility/Owner Name Facility ID#(if applicable) ft. ft.
503 Creekway Drive ft. ff. JIJL 0 8 2024
Physical Address,City,and Zip ft.
t B lc c:,•.�'; .1 1 - -,p 'JO
Caldwell z.7c/4'J7Zf y 21.REMARKS [YWt:ir3C4
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:
` Bt, 3zZ N 3SS_Yr-a- W V-,-4 4-27'2-Y
6.Is(are)the well(s) x Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or %DNo with 15A NCAC 02C.0100 or 1 SA 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: 32 (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 topcast 23.82
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