GW1-2022-05397_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
ft. ft.
A - 4475 ic. a.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if ap 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 I MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc) 0.0 ft- 15.0 ft- 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15.0 ft' 35.0 ft' 2.0 in. .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 I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 10.0 ft' PORTIANDBENTONnE SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 13.0 ft- 35.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/mck type,gimin siu,etc.
0.0 ft. 2.0 ft. CONCRETE
4.Date Well(s)Completed: 01/04/22 well ID# MW-14R 20 ft- 10.0 ft- RED SILT
5a.Well Location: 10.0 ff 20.0 ff TAN SILT
_SPEEDWAY - 7.971 20.0 ft 35.0 ft' BROWN SILT
Facility/Owner Name Facility ID#(if applicable) ft. ft. j
1343 ROCK BARN ROAD CONOVER 28613 ft. ft-
Physical Address,City,and Zip
ft. It.
CATAWBA 21.REMARKS
County Parcel Identification No.(PIN) BENTONTTE SEAL-.10.0-13.0 FEET '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ha/long is sufficient) 22.Certification:
350 43' 13.90" N 810 11' 19.57" W � 01/11/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By.signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Iflifus is a repair,fill out known well construction informalion and explain the nature ofthe ofthis record has been provided to the troll owner.
repair under k21 remarks.section or on the back ofthis 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 wel Is (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: 35.0 (ft.)
For multiple twe/Is list all depilts ifdrffereni(example-3@200'mid 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifu,ater level is above casing,use"+• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8•0 (in,) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
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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 depart I ment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing!over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: f
Form GW-I North Carolina Depamnent of Environmental Quality-Division of Water Resources Revised 6-6-20I8
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