GW1-2022-05404_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.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
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
i
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) 0.0 ft. 20.0 ft• 2.0 �_ t"• SCH 40 PVC
3.Well Use(check well use): ft. ft. i"•
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 ft. 25.0 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
❑lrrl atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 14.0 ft- PORTLANDBENTONRE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ,
19.SAND/GRAVEL PACK ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 18.0 It 25.0 fL 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/mck e, rain size,etc.
0.0 ft. 1.0 It. CONCRETE
4.Date Well(s)Completed: 02/14/22 Well ID# AS-1 1.0 It. 10.0 ft. RED CLAY
Sa.Well Location:
10.0 ft' 25.0 ft. PWR
PILOT - 682 ft. ft.
Facility/Owner Name Facility ID#(if applicable) 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- 14.0-18.0 FEET
***AIR SPARGE***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
360-04' 17.67" N 790 21' 08.10" W � %. �
G..-� � 02/18/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,/hereby certify that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or 15No 15A NC'AC 02C.0/00 or/SA NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known welt construction informalion and explain the nature of the of this 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 1 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: 25.0
firr nuilople wells list a//deplhs ifdiJfereni(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
f water level is above casing,use"+"
11.Borehole diameter: 8.0 (in,) 24b.For Infection 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
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:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources: Revised 6-6-2018