GW1-2022-07672_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 4
1.Well Contractor Information:
Irvinn Gutierrez-Bautista 14.WATER ZONES
FROM TO DESCRIPTIONS
Well Contractor Name
4504-A 255 ft- 295 ft. FINE SAND
330 ft• 350 ft. LIMESTONE,FINE SAND
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER if a" licable
A.C. Schultes of Carolina, Inc. FROM TO DIAMETER' THICKNESS MATERIAL
Company Name a. s 0 ft. 110 ft- 20 ,in. .375 CARBON STEEL
� d A t'ED
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: 6 Z 5 4Y 1ROM To DIAMETER THICKNESSMATERIAL '
List all applicable well construction permits(i.e.UIC,County,State, Var'an 0 ft. ft. in.
3.Well Use(check well use): p(�r' ! ���� ft. ft. in.
Water Supply Well: 17.SCREEN
111t#i! , FROM TO DIAMETER SI SLOT ZE THICKNESS MATERIAL
❑Agricultural OMunicipaW"-p 12 1°' .03
255 ft' 295 ft' 0 .375 316 SS
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 330 ft. 11260 ft- 12 1°' .030 .375 316SS
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT-
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 220 ft. SLURRY MIX TREMMIE
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19�SAND/GRAVELARAGIC.'tfi i'►ieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 220 ft- 355 ft. 1A TREMMIE
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary):
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock rain size etc
0 ft• 10 ft• Yellow Clay
4.Date Well(s)Completed: 9/14/2021 well ID# 15 10 ft. 70 ft. Sand and Clay
5a.Well Location: 70 ft. 80 ft. Gray Clay Rock at 75 FT
Town of Wallace 80 ft. 90 ft. Sand/Clay/Shells
Facility/Owner Name Facility ID#(if applicable) 90 ft' 95 ft. Sand
5564 Highway 41, Wallace 95 It. 110 ft. Clay and Sand
Physical Address,City,and Zip 110 ft' 129 ft. Limestone
Duplin 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer tcation:
34.744327 N 77.968495 W
6.Is(are)the well(s): OPermanent or []Temporary i ure ertt e Wy Con acto Date
By signing this for ereby certify ih the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IlNo I5A NCAC 01C. 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 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 INSTRUCTIONS
9.Total well depth below land surface: 355 (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') Submit this GW-1 within 30 daysbf well completion per the following:
59 249. 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
Ifwater level is above casing,use"+" i
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 OpentLoop 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
378 24 HR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HYPOCHLORIDE Amount: 5 GAL.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018