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HomeMy WebLinkAboutGW1-2020-00054_Well Construction - GW1_20201231 M�a�Mn WELL CONSTRUCTION RECORD NORTH CAROLINA en.lronmenmf Quurlry • Construction Electronic North • Department of • - Quality Divisionof • • September2020 CONTACT INFORMATION ...................................................................................................................................................................................................................................................................................................................................................................................... Contact Name* AMY PADGETT Email Address* apadgett@gewnc.com This will be used to email you a copyof the submitted form. WELL CONSTRUCTION INFORMATION ........................................................................................................................................................................................................................................................................................................................................................................................................................................................ 1.Who is installing these wells?* C Owner r Well Contractor 1.Well Contractor Information: .............................. Well Contractor Name NC Well Contractor Certification# Company Name DAVID HALL A-4459 GEOLOGIC EXPLORATION 2.Well Construction Permit#: List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA etc.) What type of well is this?* f Injection Well r Non-Water Supply Well f Water Supply Well(includes irrigation wells) 3. Non-Water Supply Well* r Monitoring r Recovery 4. Date well was completed and ID# Date Well Completed* Well ID# Well Yield 12/21/2020 MW-12 (gallons per minute)" 5.Well Location Facility/Owner Name* THE CORNER GROCERY Facility ID# (If applicable) County* Parcel Identification No. (PIN) Gaston Physical Address* Street Address 101 MCADENVILLE ROAD Address Line 2 City State/Proxince/Region LOWELL NC Postal/Zp Code Country 28098 USA Latitude* Longitude 35.160485 81.055588 Decimal degrees Decimal degrees ................................................................................................................................................................................ 6. Is(are)the well(s):* (-- Permanent r Temporary 7. Is this a repair to an existing well:* r Yes r No If this is a repair,fill out known well construction information and a)Plain the nature of the repair under#21 remarks section or on the back of this form. For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed. 8a. Indicate TOTAL NUMBER of wells drilled: 1 9.Total well depth below land surface:(ft.) 25' For multiple wells list all depths if different(example-3@200'and 2@100� 9a.What is the depth of the casing from ground surface? in feet 10.Static water level below top of casing:(ft.) 12' If water level is above casing,use 11. Borehole diameter: 10" in inches 12.Well construction method: 6- Auger C Air Rotary f Cable Tool C Direct Push f Mud Rotary C Rotosonic r Other 14.WATER BEARING/FRACTURE ZONES From To Description in feet in feet 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable) To From Diameter Thickness Material in feet in feet in inches 17.SCREEN From To Diameter Thickness Material 10 25 4 SCH 40 PVC in feet in feet in inches 18.GROUT From To Material Emplacment Method&Amount 5 8 PORTLAND BENTONITE SLURRY in feet in feet 19.SAND/GRAVEL PACK(if applicable) From To Material Emplacment Method 8 25 20-40 FINE SILICA SAND in feet in feet 20.DRILLING LOG From To Description (color, hardness,soil/rock type,grain size,etc.) 1 3 ASPHALT/GRAVEL in feet in feet 3 25 RED SILTY CLAY in feet in feet 21.Remarks 22.Site diagram or additional well details: You mayupload additional well construction information here. pdf only *rJ 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 copy of this record has been provided to the well owner. 23.Certification xWVjP 1- Signature of CerHed Well Contractor Submittal Date 12/31/2020