GW1--06846_Well Construction - GW1_20241115

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Weil Contractor Information:
Terry White 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3287-A ft ft. ;
ft ft. I
NC Well ContractorCASING Certification Number 15.OUTER (for multi-cased wells)OR LINER('dap 'cable)
Amer iprobe FROM TO DIAMETER , THICKNESS MATERIAL
ft. ft. in.
Company Name
WM0401560 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 ft 27 ft. 2 i in. Sch40 PVC
3.Wert Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural DMtmicipa1/Public 27 ft 42 ft 2 in. 0.010 Sch40 PVC
Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single) ft ft in.' ,
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft 25 it- Bentonite Poured/45LB
X Monitoring ['Recovery 0 ft 3 ft Neat Cement Poured/10LB
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 [JStormwaterDrainage 25 it 42 ft #2 Sand Poured
Experimental Technology DSubsidence Control ft ft
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets it necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO , DESCRIPTION(color,hardness,soi Crock type,grain size,etc.)
ft ft See Consultant Log-
4.Date Well(s)Completed:10/23/2024•Well M W-4 it ft
5a.Well Location: ft ft.
Leonard'Cleaners ft • ft. I' ::i
FaailityIOivnerName FacilitylD#(if applicable)• ft ft.
404 East Center St. Lexington 27292 ft ft , NUV 1 & 2024
Physical Address,City,and Zip ft ft "r^ +
Davidson 21.REMARKS IC,._.: ::_. . _y ✓ ..'.; ..
County Parcel IdentificationNo.(PIN) ., .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one latllong is sufficient) 22.Certification: ' .
35 49 09 N 80 14 52 w
A �_U J� 10/25/2024
ion
_ 6.Is(are)the well(s) Permanent or Dremporary Signature of Certiti l Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or I No with I5A NCAC 02C.0100 or I5A 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 wen 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:one SUBMITTAL INSTRUCTIONS j
9.Total well depth below land surface:42 (ft-) 24a. For AR 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:-
10.Static water level below top of casing:33.7 (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:4' .. m.
C ) 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: g construction to the following: i
(ie.auger',rotary,cable,direct push,etc.) '. I
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&Infect
ion 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. i
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016