GW1--05713_Well Construction - GW1_20240920

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 11-1-47
BRIAN LILLEY ::EYII : E:E3:Zt3fU;rS::>:>?:>«::?«:<>:>:»'<:?:::>::a'»>:'::?<>:>:»:::>:>:»»:::i:?':>?:> :>:: :s<::*::::::::» :>
Well Contractor Name FROM TO DESCRIPTION
380 ft. ft. 1.5 GPM
2839—A ft. ft.
NC Well Contractor Certification Number :'F5>:£EFEE:Fi':sr SSEfu£ii:(fflrmctEtl:-rased:vailIsglAi:t IPtEItilif: (l#ieabt i:ii»<i::»iiinii::::::s::=
CAROLINA VIRGINIA WELL & PUMP LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft' 103 ft• 161/4. in. SDR21 PVC
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5705W E L N23 N115:R::f~ASII�E:��:�i�OI�. .(ge �)
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 ft. 103 ft. 6 1/8 in' SDR21 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply
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Well: FROM � TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) xOResidential Water Supply(single) ft ft. ini
d tial Water Su I shared
Resl en Industrial/Commercial
PP Y
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft. 20 ft• BENTONITE SLURRY PUMPED
Monitoring Recovery' 0 ft• 3 ft. BENTONITE CHIPS POURED
Injection Well: ft. ft.
Aquifer RechargeGroundwater Remediation
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FROM TO
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Aquifer Storage and Recovery.
Aquifer MATERIAL EMPLACEMENT METHOD
AquiferTest [3StorrnwaterDrainage ft. ft.
Experimental Technology SubsidenceControl ft. ft.
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Geothermal(Closed Loop) Tracer f fY)..
0 G eothermal(H eati ng/Cooling Return) 0 Other(explain under 4421 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size etc)
0 ft• 22 ft. RED:DIRT
4.Date W l l(s)Completed:6-7-24 Well ID# 23 ft• 47 ft. BROWN DIRT
5a.Well Location: • 48 ft• 96 ft* SANDROCK
DAVID GAR DNE R 97 ft• 525 ft. GRANITE
Facility/Owner Name Facility ID#(if applicable) ft. ft. t t a !n
5226 OSCAR GAMMON RD., MEBANE, NC 27302 ft. ft.
•
Physical Address,City,and Zip ft. ft. S t r a Q iG4
A LA MA N C E 9910775020 is2E t:E...hkRKS......''iiiiiii>::i»::>::i >> :i:i s : ::::iii i:::<>:>: iiii : ....>iiiii:::...> <:
irL4.—(:-..t. WUZ County Parcel Identification No.(PIN) GIArnri:447;i:.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lorg is sufficient) 22.Certification:
N • W l � 6-7-24
6.Is(are)the well(s) X.. Permanent or Temporary Signature of Certified Well Co etor Date
By signing this fora£I hereby certify that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: -DV es or 0No- with 15A NCAC 02C.0100 or 15A 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: 525 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells listall depths if different(example-3(4)200'and 2@100') construction to the following.
10.Static water level below top of casing:40 (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 Infection Wells: In addition to sending the form to the address in 24a
AIR ROTARY 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
1.5 AIR BLOWING
13a.Y field(gpm) Method of test 24c.For Water Supply& Infection W el Is: In addition to sending the form to
the address(es) above also submif one copy of this form within 30 days of
1 13b.Disinfection type: HTH Amount: 160Z completion of well construction toithe county health department of the county
where constructed. I
Form GW-1 • North Carolina Department of E rwi ronmental Quality-Division of Water Resources Revised 2-22-2016