GW1-2022-03255_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
fit. ft. ( f
A - 2581 I
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-ca'sed'wells OR LINER if a 7icable
GEOLOGIC EXPLORATION FROM TO DIAMETER; THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) 0.0 ft- 20.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): R. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 ft' 40.0 ft' 2.0 i"' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. 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 fL 10.0 ft- PORTLANDBENTONru SLURRY
OMonitoring ❑Recovery fit. ft.
Injection Well:
ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 18.0 rt• 40.0 tr' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control tt. 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/rock type,gnin size,etc.
0.0 ft- 7.0 ft- RED SILTY CLAY
4.Date Well(s)Completed: 02/01/22 Well ID# MW-4 7.0 tt. 19.0 rt. TAN/WHITE PWR
5a.Well Location: 19.0 fir' 31.0 fit• BROWN SILTY SAND
A-1 EXPRESS 31.0 fir• 40.0 ft- TAN SILTY SAND
Facility/Owner Name Facility ID#(if applicable) ft. ft. !
603 EAST MAIN STREET LINCOLNTON 28092 ft. ft.
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 latflong is sufficient) 22.Certification:
35° 28' 26.61" N 81° 14' S7.72" W _:/:SC.. >~- 02/14/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the ivell(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I9No 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
if this is a repair,fill out known well construction information and explain the nature of'ihe of this record has been provided to the well owner.
repair under 921 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 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: 40'0 (ft)
For multiple wells list all depths ifdierent(example-3@200'and 2 ae100') Submit this GW-1 within 30 days of well completion per the following:
30.0 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
!fCrater level is above caring,use'•+" i
11.Borehole diameter 6 0 (in.) 24b. For Injection Wells: Copyjto'DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR
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 producinIz 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:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018
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