GW1-2022-07675_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 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if.e Gcable
A.C. Schultes of Carolina, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
��''+`�i •"'� S�d. (�� '�p�"'�� 16.INNER CASING OR TUBING" `eothermat closed-loop)- -- ''
2.Well Construction Permit#: ■ '^ n a �' ^�- FROM I TO DIAMETER THICK MESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,St�lare, Variance,etc.) ft. ft. in.
3.Well Use(check well use): AUG 1 8 2022 ft. ft. in.
Water Supply Well: Iftfa',�"rr '= ?� ��,C�.FY+Rj r}li 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural 1!lMuni4AyAAf;hS ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I8.GROUT'
❑hTl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. It. SLURRY MIX TREMMIE
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
OAgmfier Recharge ❑Groundwater Remediation
xn19:SAND/G"VEOPACK,'if i6 7icable <,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fa
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach.additionilsbeetsifn"essa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,eta
129 ft- 175 ft. Sand/Gray Clay/Layers of Limestone
4.Date Well(s)Completed: 9/14/2021 Well ID# 15 175 ft. 178 ft. Hard Limestone
5a.Well Location: 178 ft• 270 tt' Sandy Gray Clay
Town of Wallace 270 ft• 280 ft• Fine Sand
Facility/Owner Name Facility ID#(ifapplicable) 280 ft. 290 ft. Fine Sand and Wood
5564 Highway 41, Wallace 290 ft. 300 ft- Fine Sand/Limestone
Physical Address,City,and Zip 300 ft' 320 rt• Gray Clay/Fine Sand
Duplin 21.REMARKS ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: It A
(ifwell field,one lat/long is sufficient) 22. ;Certifi lion:
34.744327 N 77.968495 W
Al A P1 A'
6.Is(are)the well(s): OPermanent or ❑Temporary Sign e. f ertifi Vor5A
trac or Date
By signing this form,Icertify that h well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �No 15A NCAC 02C.0100CAC 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 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.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 a 100'and 1 tt✓r/00')
59 24a. For All Wells: Original form to Division of Water Resources (DWR),
]0.Static water level below top of casing: (ft) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
if water level is above casing,use"+" i
11.Borehole diameter 9 (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 Openl-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 producingf over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, ,Raleigh,NC 27699-1611
13a.Yield(gpm) 378 Method of test: 24 H R P 1611 MSC �
13b.Disinfection type: HYPOCHLORIDE Amount: 5 GAL. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
i