GW1-2022-07424_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
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1.Well Contractor Information:
DAVID HALL 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4459 p
Q�•�f ft. ft.
NC Well Contractor Certification Number _"` �{�^'' V F15.OUTER CASING for multi-cased wells R LIN if a licable
qq FROM TO DIAMETER
GEOLOGIC EXPLORATION OTH ER ICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER•CASING OR TUBING cothermal closed-loop)
2.Well Construction Permit#: ;'DD hf--z*-'S-'g Url� FROM I TO DIAMETER THICKNESS MATERIAL
I isi all applicable:cell construction permits(i.e.U1C, unty,Sta✓v' 7) 0.0 ft• 2 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 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2.0 ft' 12.0 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
❑lrri anon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0,0 ft• 1.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 1.5 ft- 12.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, inim size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
0.0 ft 4.0 ft CLAY
4.Date Well(s)Completed: 03/08/22 Well ID# MW-3 4.0 ft 12.0 ft• SAND
Sa.Well Location:
ft. ft.
GENESSEE &WYOMING ft. ft.
Facility/Owner Name Facility ID#(ifapplieable) ft. ft.
SHOULARS ROAD RICH SQUARE 27869 ft. ft.
Physical Address,City,and Zip
ft. ft.
NORTHAMPTON 21.REMARKS
Comity Parcel Identification No.(PIN) BENTONITE SEAL-1.0-1.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36a 14' 01.98" N 770 15' 00.00" N
03/17/22
6.Is(are)the well(s): (TPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the:rell(s)was 6were)constructed in accorlance with
7.is this a repair to an existing well: ❑Yes or [5No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofihis record has been provided to the we/I owner.
repair under#21 remarks section or on the back ofihis 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-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 INSTRUCTION'S
9.Total well depth below land surface: 12.0 (ft-)
1--or nuihiple we//s list all depths/J'd/Jjerent(example-3 a 200'and 2@/00� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 4.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater lerel is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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
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:
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Forni GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018