HomeMy WebLinkAboutGW1-2020-00054_Well Construction - GW1_20201231 M�a�Mn
WELL CONSTRUCTION RECORD
NORTH CAROLINA
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• Construction Electronic
North • Department of • - Quality
Divisionof • •
September2020
CONTACT INFORMATION
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Contact Name* AMY PADGETT
Email Address* apadgett@gewnc.com
This will be used to email you a copyof the submitted form.
WELL CONSTRUCTION INFORMATION
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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
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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