GW1--06220_Well Construction - GW1_20241021

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'1 ' ; '��VELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Joshua N. Robertson FRO ATER'ZOONES DESCRIPTION
Well Contractor Name ft ft 1 1.5 gpm @ 240'
2461-A ft. ft 1
NC Well Contractor Certification Number •,15::OUTER••CASING'.(for multrtased;wells)OR'-LINER(if no-licable)•` .. ,
' FROM TO DIAMETER: THICKNESS MATERIAL
, Triad Drillers, Inc. o ft 81 ft 61/8 in. .188 . PVC
Company Name :16..INNER CASING:OR TUBING-(geothermal closed-loop)"' .
2023015W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft in.
Listall applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft ft. in.
3.Well Use(check well use): .17.5CREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft ft in
ft. ft in.!
❑Geothermal(Heating/Cooling Supply) FJResidential Water Supply(single) ,
❑IndustriaVCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 20 ft Bentonite Pour
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft. .
❑Aquifer Recharge ❑Groundwater Remediation ,..;19.:SAND/GRAVEL PACK(if applicable),-- .. . .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test - ❑Stormwater Drainage ft ft
❑Experimental Technology OSubsidence Control
20:DRILLING.LOG(attach'additional sheets if necessary)`'':''--.` ..
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 12 ft Clay
10-17-23 12 ft 74 ft Sand
4.Date Well(s)Completed: Well ID#
74 ft 170 ft Shale
5a.Well Location: 170 ft 300 ft Granite
NC Custom Modulars ft ft. ;, r. t:. ; ; ;,.,,
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
122 Blackfoot Dr. ft ft OCT 1 1, 2a24
Physical Address,City,and Zip
21:'.REMARKS;::'' - = ,_ ..:
Montgomery 7653-00-03-5340 11-..-:.;;:-. ,t.i ...d., ,e y:;yw:
County Parcel Identification No.(PIN) 1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce 'ication: I e
(if well field,one lat/long is sufficient) 0
N W iv „..., `��+" 11-01-23
Signature Certified Well Contractor Date
6.Is(are)the well(s): EZIPermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance --
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IliNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide'additional well site details or well
S.Number of wells constructed: 1 construction details. You may also'attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below laud surface: 300 (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@I00') construction to the following:
10.Static water level below top of casing:
30 (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 1/8 (in.) 24b.For Injection Wells ONLY:, In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount 16 oz. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water esources Revised August 2013