GW1--06845_Well Construction - GW1_20241115

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Terry White 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION,
3287-A f` ft
It. It.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wens)OR LINER(if ap 'cable)
Amen probe FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name
WM 0401561 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 it 18 ft 2 ,in' Sch40 PVC
3.Well Use(checlrwell use): ft D j m
Water Supply Well: 17.SCREEN I
FROM TO DIAMETER SLOT SIZE THICKNESS MATFIDAi
Agricultural DMunicipai/Public 18 ft 33 n- 2 m' 0.010 Sch40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) tt ft is '
Industrial/Commercial DResidential Water Supply(shared)
1&GROUT
Irrigation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft 16 IL Bentonite Poured/31 LB
Monitoring DRecovery 0 ft 3 ft Neat Cement Poured/10LB
Injection Well:
ft It.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 16 ft 33 ft #2 Sand' Poured
Experimental Technology DSubsidence Control It. ft
Geothermal(Closed Loop) DTracer 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 Blain size,etc.)
ft 11- See Consultant Log
4.Date Well(s)Completed:10/23/2024 WellID#M W 5 ft ft.
Sa.Well Location: ft ft
Leonard Cleaners It ft I ~_ -,: —
Facility/Owner Name Facility ID#(if applicable)
ft. ft. - -- ,„.v, ; "+r V. ,i
18 North Cecil St. Lexington 27292 ft ft NU V I 2074
Physical Address,City,and Zip ft it
!r` ,_
Davidson 21.REMARKS r, - `; .i7)
:rL;
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --- ; .•—
(if well field,one 1at/long is sufficient) 22.Certification:
35 49 09 801449
N W —7 (.fJ`iGt 10/25/2024
6.Is(are)thewedl(s)DXPermanent or QITemporary SignaascoCt_CrtiGe ellCunlracwr 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: DYes or XDNo with l5A 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 Cued-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 drilled:one SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 33 (ft-) 24a.Ror 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: I
r
10.Static water level below top of casing:30.5 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(ie.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) Method of test: - 24c.For Water Supply&Infection 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: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016