GW1-2022-07642_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES t .
FROM TO I DESCRIPTION
Well Contractor Name ft. ft. b
A - 4121 ft. D.
1,
NC Well Contractor Certification Number 15.OUTER CASING forlti-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM mu
TO DIAMETER I THICKNESS MATERIAL
ft. ft. ' in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc) 0.0 ft. 20.0 ft- 2.0 t"' SCH 40 PVC
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETEW SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 fL 30.0 ft' 2.0 1O' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in!
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 it' 13.0 ft PORTLANDaENTONITE SLURRY
MMonitoring ORecovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 17.0 ft 30.0 rt• 2040 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
FROM TO DESCRIPTION color,hardness,soilhnck e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ir• 1.0 ft. GRAVEL
4.Date Well(s)Completed: 06/21/22 Well ID# MW-5 1.0 rt 21.0 ft PWR
5a.Well Location: 21.0 ff 30.0 ff ROCK
ALVARADO HOLDINGS rr. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft:
1334 EAST 11TH STREET SILER CITY 27344 ft. ft.
Physical Address,City,and Zip ft. ft.
CHATHAM 21.REMARKS
BENTONITE SEAL 13.0-17.0 FEET
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hit/long is sufficient) 22.Certification: /���,��
350 43' 52.94" N 790 26' 45.56" W �(/f 07/11/22
6.Blare)the well(s): (EPermanent or ❑Temporary Signature ofCertifted Well Contractor Date
Hy si/;nink this/brm,l hereby certify that the well(s)was(were)consirucled in accordance with
7.Is this a repair to an existing well: ❑Yes or (ENo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/J'this is a repair,Jill out known well construction ittfornal ion and explain the nature oJ'the 4/this record has been provided to the we//owner.
repair under 1t21 remarks section or on the back oj'1/us.1brni. ��:' 9,
23.Site diagram or additional Well d at s r `� .- t
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to r8.vide dlt Rat vJEII&m t-tlon info
(add'See Over'in Remarks Box).You may also attach additional ages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells A I r , x 202�
drilled: 24.SUBMITTAL INSTRUCTIONS A' ! 11
9.Total well depth below land surface: 30.0 (ft) { ,, a� t< Ur1h
P Submit this GW-I within 30 days omkfl 1,5e j?9&pe',e f�lowmg:
For multiple welts list all depths if chfPrent(example-9 a@200'and 2 r@t I00') �r ill d
25.0 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
l f water level is above casing,use"+"
11.Borehole diameter: 6'0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR 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 producine'over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Revised 6-6-2018
Fom GW-I North Carolina Department of Environmental Qualitv.Division of Water Resources
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