GW1--06185_Well Construction - GW1_20241021

Print Form . 1
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
Floyd V. Robertson '
19i WATER ZONES :. .�,;}�,.r .., '`'�,
FROM 'ro •DESCRIPTION
Well Contractor Name ft. ft.
1.5 GPM ol2de' ,
2453A ft. ft, ! '
i
NC Well Contractor Certification Number :-15:OUTER CASING(for multi cased:wells)OR LINER.(it'ap licable)r: ' .-i,-:"
Piedmont Installations (A Private Business Trust) FROM TO DIAMETER ' THICKNESS MATERIAL
q ft. 81.7 ft. 6.125 i; in. SDR 21 PVC
Company Name ,16.INNER GASINGOR TUBING'(geothermnalclosed-loop).
2.Well Construction Permit#:
2023015W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 87 ft. 4' i m' Sch.40 eve
ft. ft. 1. in.
3.Well Use(check well use):
17.'SCREEN,' .i: , ..
Water Supply Well: FROM TO DIAMETER ; SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public N/A ft• ft. in.p
I.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
It
Industrial/Commercial Residential Water Supply(shared)
FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Irrigation
Non-Water Supply Well: 0 ft. 20 ft. Bentonite • Pour
Monitoring QRecovery 0 ft. 87 ft. cam�tsaro,aam,. Pour
Injection Well:
Aquifer Recharge
ft. ft.
QGroundwater Remediation ;;19;SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery
Aquifer Test
Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Stolmwater Drainage N/A ft. ft.
Experimental Technology Subsidence Control ft. R. ,
Geothermal(Closed Loop) DTracer ,-20 DRILLINGLOG(attach`addltional sheets'if necessaryy):. ••• •'` `
FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) 0 g, 12 ft• clay
10/14/2024 12 ft. 74 ft. Sand i
4.Date Well(s)Completed: Well ID#5a.Well Location: -
rd ft. 170 ft. AAlleleit ..: Z l•r s 'i :i,...
Wendy Garner 170 ft• 300 ft• Granite;'
Facility/Owner Name Facility ID#(if applicable)
ft. ft. I OCT . i 2U24
122 Blackfoot Drive ft. ft. ' : lrf_�:;, .t P-r -c:.r
ft. ft. 1J' "::i.a's:1?
Physical Address,City,and Zip
Star, NC 27356 7653-00-03-5340 '.21 REMARKS,:, ',< i-,"' '."«_ -,.
County/n�Y1 /L�/i�JW- Parcel Identification No.(PIN) Original Drilled by Triad Drillers, Inc.2461-A on 10/17/2023
5b.Latitude and longitude`` � in degrees/minutes/seconds or decimal degrees: ;
(if well field,one lat/long is sufficient) 22.Certification: .,�,
•
35.489550 N 79.834950 �, ,Nfi _ 10/14/2024
6.Is(are)the wells)!X Permanent or Temporary
Signature of Certified Well Contractor :'- Date
By signing this fore,1 hereby certify that the well(s)was`(were)constructed in accordance
7.Is this a repair to an existing well: OYes or lNo 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS' ,
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9.Total well depth below land surface: 299 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdjerent(example-3@200'and 2@l00') construction to the following: i '
4
10.Static water level below top of casing:22. (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: 6.125 (in.) - 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary Air 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) 1'5 Method of test: Air 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: HTH Amount: 9°z• completion of well construction to!the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016
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