GW1-2022-03330_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: I ,
NICHOLAS HAYES -14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4121 ft. ft.
NC Well Contractor Certification Number I'
15.OUTER CASING for multi-casedawells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER I THICKNESS MATERIAL
0.0 ft. 55.0 ft- 6.0 i in SCH 40 PVC
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.UIC,County,State,Variance,etc.) 0.0 ft- 60.0 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 60.0 ft' 65.0 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. 50.0 ft' PORTIANDSENTONITE SLURRY
MMonitoring ❑Recovery 0.0 ft. 55.0 ft PORTLANDSENTONITE SLURRY
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 58.0 ft. 65.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control R. 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/rock type, rain siu,etc.
0.0 It. 1.0 ft. GRAVEL
4.Date Well(s)Completed: 09/1 5/21 Well ID# MW-20D 1.0 ft. 4.0 ft. GRAY SAND
5a.Well Location: 4.0 ft' 7.0 ft' TAN SAND/GRAVEL
STALLINGS STORE 7.0 ft- 55.0 ft- BROWN/TAN CLAYEY SAND
Facility/Owner Name Facility ID#(it'applicable) 55.0 ft- 65.0 TARN CLAYEY SAND �)
4708 OLD US HIGHWAY 64 ZEBULON 27597 ft. ft.
Physical Address,City,and Zip ft. ft
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL�,50.0-58.0 FEET.. +••__
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 53' 05.79" N 780 15' 49.44" W 09/27/21
6.Is(are)the well(s)• ITPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 01C.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 well owner.
repair under»21 remarks section or on the back of this form.
23.Site diagram or additional welt details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page Ito 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: 65.0 (ft.)
Far multiple wells list all depths ifdiiferent(example-3 a@,200'and 1 a 100') Submit this GW-1 within 30 days of well Completion per the following:
11.0 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
Iflrater level is above casing,use �..
11.Borehole diameter- 12.0/5.875 _(in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/MUD ROTARY
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
P
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 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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