GW1--06411_Well Construction - GW1_20241025

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Justin Marlowe •14.WATER ZONES
Well Contractor Name FROM . TO DESCRIPTION
ft. fL 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. fL I j in.
•
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WMO3O 1 376 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0 ft. 3.7 ft. 2 , ,in. sched 40 pvc
3.Well Use(check well use): ft. ft. I ID.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE , THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft- in
3.7 18.7 2 '.01 sched 40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. rnl I
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT F ' -
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1.7 ft. 2.7 fL bentonite poured
I!Monitoring ❑Recovery 0 ft. 1.7 - fL 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 2.7 ft. 19 fL #2 sand poured
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 9 ft• Residual soil
4.Date Well(s)Completed: 9/23/24 Well ID# PZ-1 9 ft 19 it PWR
5a.Well Location: ft. ft. P _
St. John Properties ft. ft •
.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. OCT ? & 2024
- 213 Fairview Road ft. ft.
Physical Address,City,and Zip ft. ft. 1 Ir,:,: . .!7::: ;),-:ram:-..-;-g L/
6>
Union K7081011 •21.REMARKS I
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 1at/long is sufficient) 22.&flifiedWell
tion:
35.088157 N -80.658048 W
_____ 9/26/2024
6.Is(are)the well(s): OPermanent or ❑Temporary Si Contractor I Date
By signing this form,I hereby certt&that the well(s)was(were)constructed ill accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A 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-I 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: 9 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
9.2 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617;MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 9 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NCI27699-1636
12.Well construction method: Auger 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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh;NC 27699-16 1 1
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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