GW1--06409_Well Construction - GW1_20241025

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Justin Marlowe 14.WATER ZONES I '
Well Contractor Name FROM TO DESCRIPTION
ft. ft I ,
4452-A ft ft
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
S&ME, Inc. FROM TO DIAMETER' THICKNESS MATERIAL
ft. ft. i 'in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WM0301376 FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 4.0 ft 2 I !rn' sched 40 PVC
3.Well Use(check well use): ft. ft. in.
IL-7.SCRE
Water Supply Well: FROM EN TO DIAMETER1' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 4.0 ft 19 ft 2 inj LO1 sched 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.l
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT I
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 2 ft. 3 ft bentonite poured
nMonitoring ❑Recovery 0 ft 2 ft cement poured
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3 ft. 19.3 ft #2 sand poured
❑Experimental Technology ❑Subsidence Control ft. ft. j
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft 13 ft Residual soil
4.Date Well(s)Completed: 9-20-24 Well ID# PZ-3 13 ft 19.3 ft PWR ,P - - •
5a.Well Location: ft. ft. !,
St. John Properties ft. ft. OCT v t, 20L4
Facility/Owner Name Facility ID#(if applicable) ft. ft < -r,r,.„gi Sr i
Irlft-4. .-.iS-i.i 'b
213 Fairview Road ft. ft. [)..1r. ,:IiJ;3
Physical Address,City,and Zip ft. ft.
Union K7081011 21.REMARKS
County Parcel Identification No.(PIN) See attached Well Construction Diagram
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certi ation:
35.086880 N -80.657074 w 7 _ 9/26/2024
6.Is(are)the well(s): I!iPermanent or ❑Temporary Si lure of Certified well Contractor Date
By signing this form,I hereby terrify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or lNo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You.may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 19.3 (ft.)
For multiple wells list all depths tf different(example-3@200'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
6.4 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: tit) Information Processing Unit,1617iMSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
1
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 9 (in.)
Program,1636 MSC,Raleigh,NC.27699-1636
n
12.Well construction method: Auger4 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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