230 Staya Way (2) r vnrr
RECO"(GW-1) For Internal Use Only:
1.Well Contractor Information: RECEIVED
C R E C E I� E D
Brian Lilley I MWATER ZONES
Well Contractor Name NOV 14
2016
L0TJ16 FROht f� TO fL DESCRIPTION
2839A 1�IU Y 45 50 fracture
tt. tL
NC Well Contractor Certification Number DG, HEALTH
15.OUTER CASING for multi-cased wells OR LINER if a lieable
Aqua D ri I I Inc FROM TO DIAMETER
THICKNESSMATERIAL
Company Name 0 ft. 23 ft. 6.25 in- sd121 pvc
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#:219664
`IG G A FROM TO DIAMETER THICKNESS MATERIAL
Gist all applicable well construction permits(h e.WC,Counly,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 0 it. ft. in.
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft. pL In.
IndustriaVCommercial DResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&MOUNT
Non-Water Supply Well: 0 ft. 20 ft• bentonite pump 2 bags
Monitoring ORecovery ft. ft.
Injection Well: ft, ft.
Aquifer Recharge E]Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
:)Aquifer Storage and Recovery [Salinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
Aquifer Test C)StormwaterDrainage ft. ft.
Experimental Technology [)Subsidence Control
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additionalsheets if necessary)
Geothermal(Heating/Cooling Retum) FlOther(e lain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil rock q Vmln i eta)
0 ft- 10 ft• sandy soil
4.Date Well(s)Completed:11-8-16 Well ID# 10 ft• 15 ft. sand rock
5a.Well Location: 15 ft. 23 ft- qranite
Brian Stanbery ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
230 staya Way Ln Mocksville NC 27028 ft. ft.
Physical Address,City,and zip ft. ft.
davie 5842521769 21,REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22.Cerfafi ation:�`°
36 01.5 N 80 32'16.5 W �� _ 11-8-16
6.Is(are)the well(s)oPermanent or OTemporary Signatu�ta ofrCertifledell Co ctor Date
By sibvting this form, hereby cert that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or x JNo with ISR NCAC 01C. /00 r ISA NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction Information and explain the nature ofthe copy ofthis record h e provided to the well owner.
repair under#21 remarks section or an the back ofthisform. 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths If dierent(example-3(x)200'and 2(x1/00) construction t0 the following:
10.Static water level below top of casing:45 (ft.) Division ofWater Resources,Information Processing Unit,
Iflvaterlevel is above casing:use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 13 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
air rotary above,also submit one copy of this form within 30 days of completion of well(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)25 Method of test:blow 24c.For Water SuDDIv&Iniection Wells: In addition to sending the form to
hth70% . 12oZ the addresses) 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