GW1-2022-03353_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATERZONEs
CARL CARPENTER r
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
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A - 4475 ft. ft. I'
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased`,wells OR LINER if a dcable
FROM TO DIAMETER, THICKNESS MATERIAL
GEOLOGIC EXPLORATION, INC fr. e. yin•
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER' THICKNESS I MATERIAL
2.Well Construction Permit#: 0.0 ft' 20.0 ft' 2.0 i t"' SCH 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 It' 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
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrl ation 0.0 It. 150 ft* PORTLANDaENTONITE SLURRY
Non-Water Supply Well:
mMonitoring ORecovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier 18.0 R. 25.0 It' 20-40 FINE SILICA SAND
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness soiltrock type,grain sir,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0.0 It. 2.0 ft- ASPHALT/GRAVEL
11/11/21 AS-1 2.0 ft. 10.0 ft- BROWN SAND
4.Date Well(s)Completed: Well ID#
10.0 ft. 15.0 ft. TAN SILTY CLAY
Sa.Well Location: 15.0 It• 25.0 It• i r GRAY SILTY SAND
COUNTRY CUPBOARD
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. a r�
4915 US HIGHWAY 15 CARTHAGE 28327 ft. rt 11
Physical Address,City,and Zip 21.REMARKS
MOORE BENTONITE SEAL 15.0-18.0 FEET ,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one fat/long is sufficient) �
350 18' 56.81" N 790 24' 54.07" W C 11/16/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): IZPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
ivith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthts record has been provided to the well owner.
/f this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Pbr multiple injection or non-water supply wells ONLY with the same construction,you can
submit one.form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25.0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
F'or multiple wells list all depths ifdii ferem(example-3 r@200'and 2@ 100') construction to the following:
10.Static water level below top of casing: 9'0 (ft.) Division of Water Quality,Information Processing Unit,
Ifwaler level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
AUGER above, also submit a copy of this;form within 30 days of completion of well
12.Well construction method: construction to the following:
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(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&.Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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