GW1-2022-01904_Well Construction - GW1_20220228

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NORTH CAROLINA
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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2022-01904
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Alton Boshoff [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........ ......... ..... ......... ......... ......... ......... ..... .........
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
2595 A ALTON BOSHOFF GEO SUPPORT INC
2.Well Construction Permit#:
NA
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well (includes irrigation wells)
3.Non-Water Supply Well* Monitoring
Recovery
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
2/10/2022 M W-1 NA
(gallons per minute)"
5.Well Location
........ ......... ......... ......... .... ..... ......... ......... ......... ......... ......... ..... .... ......... ......... ......... ......... ........................... ...

Facility/Owner Name* Facility ID#
John Dutton 0036436
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Wake 1711241246
Physical Address* Street Address
200 Vandora Springs Road
Address Line 2
City State/Province/Region
Garner NC
Postal/Zip Code Country
27529-3044 US
Latitude* 35.7126186000 Longitude*78.6201606000
Decimal degrees Decimal degrees
... ......... ......... ......... ......... .....
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes • No
If this is a repair,fill out known well construction information and explain 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.) 9a.What is the depth of the casing from ground
28 surface?
For multiple wells list all depths if different 13
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
18.95 6
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
14.WATER BEARING/FRACTURE ZONES
From To Description
17 28 Moisture noticed in sandy layer and getting wetter with depth.
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN

From To Diameter Thickness Material
13.00 28.00 2.00 0.01 inch slot SCH40 PVC
in feet in feet in inches
18.GROUT
.....................................................................................................
From To Material Emplacment Method&Amount
0.30 3.00 Portland Cement Poured
in feet in feet
3.00 11.00 Bentonite pellets Poured&hydrated
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
11.00 28.00 #2 Filter Sand Poured
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 14.00 Gray quarry fill
in feet in feet
14.00 28.00 Tan sandy clay
in feet in feet
21. Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
* 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
Signature of Certified Well Contractor