GW1-2022-03251_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information: E
BRIAN THOMAS 1a.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. {
A - 2581
NC Well Contractor Certification Number I'
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 well construction permits(i.e.UIC,County,Slate,Variance,etc) 0•0 rt• 20.0 ft- 2.0 i"• 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 20.0 rt• 40.0 ft' 2.0 in.` .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 10.0 fr' PORTLANDaENTONITE SLURRY
OMonitoring ❑Recovery R. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stotmwater Drainage 18.0 ft- 40.0 ft• 20-46 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 TO DESCRIPTION color,hardness,soil/mck type,grain sin,etc.
0.0 fr• 11.0 fL RED SILTY CLAY
4.Date Well(s)Completed: 02/01/22 Well ID# MW-8 11.0 ft 18.0 ft TAN/WHITE PWR
5a.Well Location: 18.0 ft' 28.0 rt' BROWN SILTY SAND
A-1 EXPRESS 28.0 ft- 40.0 ft' TAN SILTY SAND
Facility/Owner Name Facility ID#(ifapplicable) -
603 EAST MAIN STREET LINCOLNTON 28092 ft• ft. a
Physical Address,City,and Zip ft. ft.
LINCOLN 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL. 10.0-18.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certification:
3SO 28' 26.61" N 810 14' 57.72" W t->~... Gar- 02/14/22
6.Is(are)the well(s): (EPermanent or OTemporary Signature of Certified Well Contractor Date
By signing ihis 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 I!5No ISA NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
/flhis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under IF21 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 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: 40.0 (ftJ
For multiple wells list all depths ifdierent(example-3 a 00'and 1Q100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 30.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
/fwater level is above casing,use"+•' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.0 (in.) 24b. For Infection Wells: Copy to PWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC'AIR 27699-1636
12.Well construction method: 24c.For Water Supply and Opeo-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 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:
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Form GW-I North Carolina Department of Environmental Quality-Division of water Resource I s Revised 6-6-2018
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