GW1-2022-05396_Well Construction - GW1_20220311

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
ft. ft.
A - 4459
rr. rt.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS We
ft. ft. ( in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc) 0.0 ft. 18.0 ft. 2.0 In' SCH 40 PVC
3.Well Use(check well use):
ft. ft.
17.SCREEN
Water Supply Well: FROM TO DIAMETER:, SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 18.0 ft. 38.0 ft' 2.0 i"• .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01rr1 ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It. 13.0 ft- PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery R. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 16.0 ft• 38.0 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) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
0.0 It. 1.0 ft• CONCRETE/GRAVEL
4.Date Well(s)Completed: 01/05/22 well ID# MW-3I 1.0 ft• 38.0 ft• CLAYEY SAND
5a.Well Location:
SPEEDWAY - 7971
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. f
1343 ROCK BARN ROAD CONOVER 28613
Physical Address,City,and Zip ft. ft.
CATAWBA 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 13.0-16.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient) 22.Certification:
350 43' 13.85" N 81 0 11' 19.33" w 01/11/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this Jorm,I hereby certify that the well(s)was(were)constructed in accordance ivuh
7.Is this a repair to an existing well: ❑Yes or I9No I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
IJ.this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back of this 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-1 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: 38.0 (ft.)
(br multiple wells list all depths if-different(example-3 rer 200'and 2 r@100') Submit this GW-1 within 30 days of well completion per the following:
10. 27.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
/f
$.0 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource's Revised 6-6-20I8
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