GW1-2022-03315_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES 1
FROM TO DESCRIPTION
Well Contractor Name
ft.
A - 4475 ft. ft.
NC Well Contractor Certification Number I
15.OUTER CASING for roul6-cased'wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICKNESS MATERIAL
ft. ft. I in.
Company Name ,.
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable irell construction permits(i.e.UIC,County,State, Variance,etc.) 0.0 ft- 40.0 ft- 2.0 in. 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 40.0 ft' 45.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) H. 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- 35.0 ft- PORTLANDSENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. 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 38.0 ft• 45.0 It. 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) OOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
0.0 ft• 2.0 fL TOPSOIL
4.Date Well(s)Completed: 12/20/21 Well ID# AS-2 2.0 ft. 10.0 ft- RED SILTY CLAY
Sa.Well Location: 10.0 ft. ft' TAN SILT
30.0 :-
AMOS GROCERY 30.0 ft• 45.0 ft. BROWN SILT
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. MAR 1 4 ,f1O7
5378 NC HIGHWAY 704 SANDY RIDGE 27046 ft• ft. l�(
Physical Address,City,and Zip ft. ft. t .
STOKES 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL 35.0-38.0 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 29' 20.17" N 800 05' 38.33" W f G-; -� 12/29/21
6.Is(are)the well(s)• OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(trere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or INNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the trell owner.
repair under.21 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: 45.0 (ft.)
For multiple hells list all depths if-different(example-3 a 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easing: 30.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lflrater level is above casing,use'
11.Borehole diameter: 8.0 (in.) 24b. For Injection 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
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ver 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources si Revised 6-6-2018