GW1--04045_Well Construction - GW1_20240708

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I7
1.Well Contractor Information:
Ronald F. Barron 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
fL ft. Uneonolldsted
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. 24 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 24 ft. 39 ft. 2 in' olo Sch 40 PVC
Geothermal(Heating/Cooling Supply) D Residential Water Supply(single) ft, ft, in.
0 Industrial/Commercial D Residential Water Supply(shared) 18.GROUT
-"Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 1e ft. Concrete Poured
x�Monitoring ['Recovery 18 ft. P1 !t. ab sent,ale chips Poured
Injection Well:
ft. ft.
Aquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ['Stormwater Drainage 21 ft. 39 ft. Filter sand Poured
Experimental Technology ['Subsidence Control ft. ft.
Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soR/rock type,grain size,etc.)
JGeothermal(Heating/Cooling Return) f Other(explain under#21 Remarks)
o fL 1 ft. Gravel
4.Date Well(s)Completed:6-4-24 Well ID#MW-8 1 ft 16 it Bm Blk Silty Clay
5a.Well Location: ,a ft. 39 ft. White Tar silty sand PWR
DAHH Ventures LLC clo David Hamby NCDEQ Incident#13052 ft ft. t ``I ' /
v Facility/Owner Name Facility ID#(if applicable) ft. ft'
503 Creekway Drive ft. ft. JUL 0 8 t0t4
Physical Address,City,and Zip ft ft f i
nt
Caldwell 27V9137Z.S-47 4/ 21.REMARKS Oth'f1rlfGei
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:
Pal 3.7 z Z N 3r; S'yrz W /l0.14--.c0 '-- Gv •2.7 2 V
6.Is(are)the well(s)fx 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: ['Yes or ElNo with 15A 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#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:"'A SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 39' (N-) 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 top of casing:26.60 (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