GW1-2022-07832_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATEWZONES
FROM TO I DESCRIPTION
Well Contractor Name
ft. ft.
A - 4475 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased<wells OR LINER if a' EA61e
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.'INNER CASING OR':TUBING eotherniud,cldsed-loop)
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. 5.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.Water Supply Well: FROSM REENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 tt' 20.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 718.GROUT
❑Irrl atlon ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It- 2.0 ft' PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. fa
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAYEli'PACK'if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3.0 ft- 20.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.,DRILLINGILOG(Attach..additiuii sheetsufiiecessil? ,'X
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/ruck type,grain size,etc.
0.0 ft. 1.0 ft. CONCRETE
4.Date Well(s)Completed: 06/20/22 Well ID# MW-7 1.0 ft. 10.0 ft. RED SILTY CLAY
5a.Well Location: 10.0 fl' 20.0 ft' j BROWN SILTY CLAY
CIRCLE K - 2723843 ft. ft.
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Facility/Owner Name Facility ID#(if applicable) ft. ft.
4470 NC - 87 SANFORD 27332 ft. ft.
Physical Address,City,and Zip ft. ft
LEE 21REMARKS'
County Parcel Identification No.(PIN) BENTONITE SEAL-2.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 25' 26.36" 790 07' 15.05"
N w 711A
6.Is(are)the well(s): (Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the well(s)was(tyga(e,1 n9rudr�ed=dance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cotrttii''ttjj�aJJcc�itlomStatda that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe 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 detaiO�''f mauc A1Pf.^.co cv;rg UrA
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
You may use the back of this page;to provide addition aP we r�ction 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: 20.0 (ft.)
For multiple wells list all depths ifdif/erent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.0 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
If water level is above casing,use"+"
11.Borehole diameter:
8.0 (in.) 24b.For Injection Wells: Copy to;DWR,Underground Injection Control(IUC)
AUGER Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: 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 producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
139.Yield(gpm) Method of test:
13b.Disinfection type: Amount: p
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Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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