GW1-2022-07807_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.-:WATER ZONES,,,--,,,,;; 'i'
Well Contractor Name FROM TO I DESCRIPTION
A - 4459 a. rr.
NC Well Contractor Certification Number OUTER CASING fok ruulti-cast.*dls'ORtiINER ifs "7kablt
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICIQVESS MATERIAL 7
ft. fL in.
' Company Name
Z,'16aINNER-CASING'OR_'TI)BING cothermal dosed-1666
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 25.0 ft. 2.0 ! In' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0"' 35.0 ft• 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '38.GROUT,
❑Irrl ation ❑Wells>100000GPD FROM TO "MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 20.0 ft. PORTIAND BENTONITE SLURRY
InMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
'19."$AND/GRA�'Eli'PACK if a"licable ;"'�•` '`
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test ❑Stormwater Drainage 23.0 1" 35.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer
20.DRILLING"'LOG attach"ad"diNoiiat'stieets if'oecessa " ,,,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRD'TION color,hardness,soil/rock type,grain Size,etc.
0.0 fi- 35.0 ft- SILTY CLAY
4.Date Well(s)Completed: 07/18/22 Well ID# MW-7 ft. ft.
5a.Well Location: ft. ft.
_REGINA LEWIS PROPERTY ft. rL �-
Facility/Owner Name Facility ID#(ifapplicable) ft. " It. A U r 1 9 2022
11608 NC - 62 BURLINGTON 27217 ft. ft.
Physical Address,City,and Zip ft. ft. [A11JQi30C_
GUILFORD 21REMARKS"4nti
County Parcel Identification No.(PIN) BENTONITE SEAL-20.0-23.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latpong is sufficient) 22.Certification:
360 15' 52.61" N 790 20' 28.35" W �. �•-�-e�
07/29/22
6.Is(are)the well(s): 09Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 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 afthis 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: 35•0 (ft.)
For multiple wells list all depths iit dierent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
32.0 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
Ifwater level is above casing,use"+"
11.Borehole diameter. 8.0 (in,) 24b.For Injection Wells:Copy to i DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
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Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources j. Revised 6-6-2018
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