GW1-2022-06444_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER -14WATERZONES-
Well Contractor Name FROM TO DESCRIPTION
ft.
A -4475 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased.wells OR LINER if"a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. is
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County•State,Variance,etc.) 0.0 ft. 54.0 ft-T 2.0 1" SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 54.0 ft' 59.0 ft• 2.0 in.
010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑lndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
01ni ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 50.0 ft' PORTLAND BENTONITE SLURRY
OMonitoring ❑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 EMPLACEMENTMErHOD
❑Aquifer Test ❑StormwaterDrainage 52.0 ft. 59.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type.grain size,etc.
0.0 ft. 1.0 ft• TOPSOIL
4.Date Well(s)Completed: 04/04/22 Well ID# MW-10 1.0 ft. 10.0 ft. RED SILTY CLAY
5a.Well Location: 10.0 ft' 30.0 ft' BROWN SILTY CLAY
PILOT - 57 30.0 ft. 59.0 ft. TAN SILTY SAND/ROCK
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1342 TROLLINGWOOD HAWFIELDS ROAD MEBANE 27302 ft. ft.
Physical Address,City,and Zip
ft. ft.
ALAMAN CE '21.REMARKS,:
County Parcel Identification No.(PIN) BENTONITE SEAL-50.0-52.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:.
(if well field,one lat/long is sufficient) 22.Certification:
360 03' 56.01" N 790 18' 36.52" W �,�
G`�� 04/25/22
6.Is(are)the well(s): 191'ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cent fy that the well(s)ivas(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Constructioonta Standards and that a copy
Ifthis is a repair,fill out known ivell construction information and explain the nature ofthe ofthis 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 well details:
8.For Geo robe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additio,}�at�well construction info
P P g (add'See Over'in Remarks Box).You may also atlaclitaldifiorial�agesifnecessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Totall well depth below land surface: 59.0 (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
15.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+"
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b.For Injection Wells: Copy to DVM Underground Injection Control(NC)
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(gP m) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 Noah Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018