GW1-2022-05394_Well Construction - GW1_20220311

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 4475 ft. ft.
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells)OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name -
16.INNER CASING OR TUBING(geothermal closed-loop)-
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable uell construction permits(i.e.U1C,County,State,Variance,etc) 0.0 ft. 5.0 ft' 4.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft' 10.0 ft' 4.0 tn'
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 2.0 rt' PORTLANDaENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK it a' licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 tt• 10.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ItOther(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft 1.0 ft. CONCRETE
4.Date Well(s)Completed: 02/14/22 Well ID# SVE-1 1.0 ft. 10.0 ft. RED CLAY
rt. ft.
Sa.Well Location:
PILOT - 682
Facility/Owner'Name Facility ID#(ifapplicable) ft. ft. ` -
1043 JIMMIE KERR ROAD HAW RIVER 27258 ft. ft.
Physical Address,City,and Zip ft. ft.
ALAMANCE 21;REMARKS,
County Parcel Identification No.(PIN) BENTONITE SEAL-2.0-4.0 FEET
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Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***SOIL VAPOR EXTRACTION
(if well field,one lat/long is sufficient) 22.Certification:
360 04' 17.67" N 790 21' 08.10" w 02/18/22
6.Is(are)the well(s): (Permanent or ❑Temporary Signature of Certified Well Contractor Date
By.signing this form,l hereby cerlify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [5No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
//'this is a repair,fill out known well construction infbrmalion and explain the nature o/the of this record has been provided to the we//owner.
repair under#21 remarks section or on the back q/7his 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 construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 10.0 (ft.)
Fbr multiple wells list al/depths ifdiffereni(example-3@200'and 2a/00') Submit this GW-1 within 30 days,of well completion per the following:
24a. For All Wells: Original foiin to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lf eater level is above casing,use"+"
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinaiover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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