GW1--04043_Well Construction - GW1_20240708

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: INIMIIIMIIIIIMIMMII
1.Well Contractor Information:
Ronald F. Barron 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft
2091-A ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap likable)
Piedmont Industrial Services FROM TO DIAMETER THICKNESS MATERIAI.
0 ft. 22 5 ft' 2 in. Soh 40 PVC
Company Name
W M 0100579 16.INNER CASING OR TUBING(geothermal closed-loop)
Z.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
0Agricultural OMunicipal/Public 22.5 ft. 37.5 ft' 2 in. .010 Sch 40 Pvc
DGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
IDIndustrial/Commercial 0Residential Water Supply(shared) 18.GROUT
')Irrigation FROM TO NI ATERIAI._ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 18 ft• Concrete Poured
X3Monitoring 0 Recovery 18 ft' 20 ft. sss.ewe.mip. Poured
Injection Well:
ft. ft.
BAquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAI. EMPLACEMENT METHOD
Aquifer Test ID Stormwater Drainage 20 ft. 37.5 ft. Filter sand Poured
Experimental Technology 0 Subsidence Control ft. ft.
IDGeothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type Praia size etc.)
0 ft. 1 ft. Gravel
4.Date Well(s)Completed:6-4-24 Well ID#MW-1 1 1 ft. 16 ft. Bm Blk Silty Clay
5a.Well Location: ,, ft. 37.5 ft. White Tan silty sand PWR
DAHH Ventures LLC c/o David Hamby NCDEQ Incident#13052 fr. ft. .
Facility/Owner Name Facility ID#(if applicable) ft. ft. i \` R. /E D
503 Creekway Drive ft. ft. l_a s�Q 22d
Physical Address,City,and Zip ft. ft.
Caldwell z-74V37zro y 21.REMARKS Irkwir.tAt,r,1 :'.--..se*,41 IlltiE
CY.A.(:u SCt;
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:
-Sl, 3 /�. j
32 Z- N 31 r S��Z W
=Jc 0-9 L�f4-e-- G
6.Is(are)the well(s) % Permanent or "temporary Signature of Certified Well Contractor Date -7-7-Zr
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: Dyes or ElNo with ISA NCAC 02C.0100 or ISA 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#11 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:CA SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 37.5' 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-3Q200'and 2@100) construction to the following:
10.Static water level below topof casing:27.42
(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 SUDDly&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