GW1-2022-07805_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL f 14.WATER:ZONEs
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4459 ft. ft .
NC Well Contractor Certification Number <'15 OUTER CASINGS for multi-cated,w`elld lORiNERi`ffie""liihble
GEOLOGIC EXPLORATION FROM TO DIAMETER TH1.-IICKNESS MATERIAL
fr. ft. in.
Company Name
,16.INNER CASING OR TUBING 'eothermal dosed-16o
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well consintction permits(i.e.U1C,County,State,Variance,etc) 0.0 ft. 25.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): fr. ft in.
Water Supply Well: 17 SCREEN,
..
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 fr' 40.0 ft• 2.0 rD' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. is
❑Industrial/Commercial ❑Residential Water Supply(shared) 7T8.GROUT
❑1rTI ation ❑Wells>100000GPD FROM TO ✓\ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 20.0 ft PORTLANDBENTONITE SLURRY
29Monitoring ❑Recovery ft. fa
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
a 1%SAND/GRAVEL,PACK'if a 'lieAble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METH OD
❑Aquifer Test ❑Stormwater Drainage 23.0 ft- 40.0 ft 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer `30r:DRILLING LOG sttae6'additioaal'.'sheets if oeceisA
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size etc.
0.0 fr• 40.0 fL SILTY CLAY
4.Date Well(s)Completed: 07/19/22 Well ID# MW-5 ft. ft.
5a.Well Location: ft. ft. •
REGINA LEWIS PROPERTY ft. ft. .V_4--
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. AV,
tI r
11608 NC - 62 BURLINGTON 27217 rt. ft.
Physical Address,City,and Zip ft. ft
GUILFORD '•21..REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-20.0-23.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification-.
360 15' 52.61" N 790 20' 28.35" W 07/29/22
6.Is(are)the well(s): (Permanent or ❑Temporary Signature ofCeni6ed Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I9No 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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: 40.0 (ft.)
For multiple wells list a//depths ifdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days well completion per the following:
10.Static water level below top of casing: 32•0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Suably 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
13s.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleig�,h,NC 27699-1611
13b.Disinfection type: Amount:
ti
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources,, Revised 6-6-2018