GW1-2022-07669_Well Construction - GW1_20220818

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Winn Gutierrez-Bautista 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4504-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi;-cased w Its OR LINER 'if a Gcable
A.C. Schultes of Carolina, I11C. N 0 IV_ tl FROM TO DIAMETERi THICKNESS MATERIAL
f ft. ft. !in.
Company Name
ti -16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: AUG ! S 2022 FROM TO I DIAMETER! THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate, Variance,etc.)
In`crr+;Uon PrncaG artg Unh
3.Well Use(check well use): D%NCYBOG ft. ft.
Water Supply Well: 7.SCREEN
777,77
FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
❑Agricultural CJMunicipal/Public ft. ft. i in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑❑Industrial/Commercial Residential Water Supply shared
pp y(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&ADIOUNT
Non-Water Supply Well: ft. ft• SLURRY MIX TREMMIE
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19 SAND/GRAYEIfiPAGK'if a"livable ?_`
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain size etc
320 ft- 340 ft Gray Clay/Lime Sand/Limestone
4.Date Well(s)Completed. 9/14/2021 well ID# 15 340 ft. 350 ft Fine Sand/Wood/Gray Clay
5a.Well Location: 350 ft. 360 ft- Fine Sand and Wood
Town of Wallace 360 ft. 370 ft- Gray Clay/Hard Rock
Facility/Owner Name Facility ID#(ifapplicable) 370 ft. 380 ft- Gray Clay/Hard Rock/Sand
5564 Highway 41, Wallace 380 ft. 400 ft- Gray Clay/Small Trace of Sand
Physical Address,City,and Zip ft. ft.
Duplln 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) dA
rtification•
34.744327 N 77.968495 W
6.Is(are)the well(s): InPermanent or ❑Temporary e o Certi ed ell ontractor Date "I
By signing this fo t hereby cerl a!the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8NO 15A NCAC 02C. 00 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
1f lhis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#11 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 provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 355 (ft
For multiple wells list all depths fdifferent(example-3@200'and 1@100') ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 59 (ft) 24a. For All Wells: Original form;to Division of Water Resources (DWR),
1f water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 19 (in) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
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
139.Yield(gpm) 378 Method of test: 24 H R
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HYPOCHLORIDE Amount: 5 GAL.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018