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Home My WebLink AboutGW1--05947_Well Construction - GW1_20241009 Print Form I WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: . ' 1.Well Contractor Information: i Gy� ,!loyd Mares 14.WATERZONES Well Contractor Name FROM TO , DESCRIPTION ft. ft. 2547-A ft. ft. i NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) Register Well Co., Inc. FROM TO DIAMETER . THICKNESS MATERIAL 0 ft' 270 ft. 4 1 .40 pvc Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) 2.Well Construction Permit#: I FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. i in. 3.Well Use(check well use): ft ft. in. N Water Supply Well: FROM TO _ DIAMETER SLOT SIZE THICKNESS MATERIAL ®Agricultural QMunicipal/Public 270 ft. 290 ft. 4 in. .016 pvc ®Geothermal(Heating/Cooling Supply) Ix Residential Water Supply(single) ft. ft. in.I. N Industrial/Commercial DResidential Water Supply(shared) 18.GROUT I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft• 20 ft hole plug poiur *Monitoring QRecovery ft. ft. Injection Well: **Aquifer Recharge QGroundwater Remediation ft. ft. 19.SAND/GRAVEL PACK(if applicable) %Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD *Aquifer Test DStormwater Drainage 269 ft. 290 ft. #2 gravel pour ill Experimental Technology [Subsidence Control ft. ft. ®i Geothermal(Closed Loop) Ej Tracer 20.DRILLING LOG(attach additional sheets if necessary) . FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) 01 Geothermal(Heating/Cooling Return) •rOther(explain under#21 Remarks) 0 ft. 15 ft. sand clay mix 4.Date Well(s)Completed:09/18/24, , Well ID# ,_ 15 ft. , 35 " ft. _clay. 5a.Well Location: 35 ft. 60 ft• sand medium coarse Kevin Bridges - 60 . ft 68 ft. clay' • • -.; _ __ - Fadility/Owner Name -' Facility ID#(if applicable) . ,.. 68 ft. . 80 _ft .sand'Clay layers .t C...;il. ..,.t,, .:t, '.,/j,N j 2202 E Mt. Gilead-Cll. Rd. Clinton 80. ft. 107 ft• •sand medium Physical Address,City,and Zip 107 ft. 116 ft. Clay .. OCT ii92024 sampson 21.REMARKS li,:v::', -tY 1...'3: County • Parcel Identification No.(PIN) li`t i'••:.•-'r' 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certification: ' 34.888304 -78.237807 9/30/24 N W / / /1/ P 1 7,. 3 6.Is(are)the well(s) !X;Permanent or Temporary �Siignawtuturee oo ertiifi/ed 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: QYes 'or Eli No 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#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: 290 (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 top of casing:64 (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 3/4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a . 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,directpush,etc.) -.-.. . . I ' I Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636.Mail Service Center,Raleigh,NC 27699-1636 13a.'Yield(gpm) 50(1 00) Method of test:air. 24c. For Water Suauly&Iniection 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: hth Amount: 8 OZ completion of well construction to the county health department of the county where constructed. I I Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016 . I ' I , i ! 5. . CUSTOMER: ! ,LAu &,8r, ADDRESS: -2.9(1.2 eff. --'/ (..-:-/.1:.-4,-/i:':,-,;>,, ..;' .,,,' 4; 1 I ' THICKNESS FORMATION THICKNESS FORMATION FROM TO (CLAY,SAND,ROCK,ETC.) FROM TO ,- I (CLAY,SAND,ROCK,ETC.) , .' - . 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