GW1-2022-06440_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Us6 Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES-',.'
Well Contractor Name FROM TO DESCRIPTIONI
ft. ft
A - 4475 ft. ft
NC Well Contractor Certification Number
AS.OUTER'CASING,for TH!t,-_c-edw-cHs1 0 7 DIAM".
". %=apV,.ble)
GEOLOGIC EXPLORATION FROM T MATERIAL
ft. ft. in.
Company Name I I
16.INNERCASING OR TUBING(6othermal closed-loo'�)
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. 10.0 ft. 2.0 SCH 40 PVC
3.Well Use(check well use): % ft. in.
�Al`.SCREEN,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
oAgricultural E]MunicipaVPublic 10.0 f"' 20.0 ft' 2.0 in- .010 SCH 40 PVC
C]Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
DIndustrial/Commercial DResidential Water Supply(shared)
18.GROUT
ObTigation oWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 6.0 ft- PORTLAND B,ENTONITE SLURRY
11flMonitoring ORecovery ft. ft.
Injection Well:
ft. ft.
[]Aquifer Recharge 0 Groundwater Remediation -19.SAND/GRAVEL PACK(ifatipticable)
•Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•Aquifer Test oStormwater Drainage 8.0 "- 20.0 ft- 20-40 FINE SILICA SAND
E]Fxperimental Technology ElSubsidence Control ft. ft.
oGeothermal(Closed Loop) Effracer 20.DRILLING'LOG(attach additional sheets if necessary)
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiYnck type,grain size,etc.)
0.0 ft. 1.0 ft. TOPSOIL
4.Date Well(s)Completed: 04/05/22 Well ID# MW-6 1-0 ft. 10.0 ft. RED SILTY CLAY
5a.Well Location: 10.0 1" 20.0 It' BROWN SILTY CLAY
PILOT- 57 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1342 TROLLINGWOOD HAWFIELDS ROAD MEBANE 27302 ft. ft.
Physical Address,City,and Zip ft. ft.
ALAMANCE 21.REMARKS'114N`�:
County Parcel Identification No.(PIN) BENTONITE SEAL-6.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
360 03' 5820" N 790 18' 35.55" W 04/25/22
6.Is(are)the well(s): 11flPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or MNo 15A NC4C 02C.0100 or 15A NCAC 02C.0200 Well ConstruErja"dards and that a copy
Ifthis is a repair,fill out known ivell construction information and explain the nature ofthe ofthis record has beenprovided to the Nell 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 provideVdaition"a'l�elperffnRruction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER ofwells (add'See Ovee in Remarks Box).You may also 0'22 additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20.0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifilifferent(example-3@200'and 2@100)
10.Static water level below top of casing: 10.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
II.Borehole diameter. 8.0 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
(in.) 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
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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20 18