GW1-2022-07670_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Irvinn Gutierrez-Bautista 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4504-A
NC Well Contractor Certification Number 15 OUTER CASING for multi-cased wells'-OR LINER if a Ii able
A.C. Schultes of Carolina, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. �in.
Company Name l6.INNER CASING ORTUBING' eoihermal closed-loop)
2.Well Construction Permit#: .--->­N 'P.' ,6 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,Ccrt,, t 4,(;pr wi ell)1., ft. ft. in.
3.Well Use(check well use): -j 02Z ft. ft. in.
Water Supply Well: 17.SCREEN
�Jf1iI FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Cl Dlviico`f��it ft ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential 4f'St y'(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well,
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
4A49 SAND/GRAVEL"P.A'GK'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets,ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain size,etc
268 ft• 298 ft- Fine Sand/Wood/Gray Clay
4.Date Well(s)Completed: 10/13/2021 Well ID# 16 298 ft. 308 ft Clay/Trace of Shells
5a.Well Location: 308 ft' 318 ft- Clay/Trace of Shells
Town of Wallace 318 It' 338 ft- Gray Clay/Sand Licnite
Facility/Owner Name Facility ID#(if applicable) 338 ft• 348 ft- Gray Clay
108 Eastwood Street, Wallace 348 ft- 403 ft- Sandy Clay
Physical Address,City,and Zip
ft. ft.
Duplin 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. ertification:
34.74837 N 77.96272 W
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6.Is(are)the well(s): InPermanent or ❑Temporary gna a ed e o t r ate
By signing this arm, hereby certi at the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02 .0 0 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 of this 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 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 Ovet'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 385 (ft.)
For multiple wells list all depths i(dr/fereni(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
60 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
lfwater level is above casing,use"+"
11.Borehole diameter 9 (in,) 24b. For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary k
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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinglover 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield m 422 Method of test: 24 H R Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gP )
13b.Disinfection type: HYPOCHLORIDE Amount: 5 GAL
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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