GW1-2022-07833_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name
ft. ft.
A - 4475 ft. fL
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased;wells.OR LINER if a licable
GEOLOGIC EXPLORATION FROM To DIAMETER' THIC•IOESS MATERIAL
1 EXPLORATION�1 �V ft. ft. i! in.
Company Name
MANNER CASING OR TUBING iothermal closed loo
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 1O SCH 40 PVC
3.Well Use(check well use): ft. ft. t ,rn
Water Supply Well: 17 SCREEN
PPY FROM TO DIAMETEW SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 fL 20.0 rt' 2.0 in-, .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 2.0 ft' PORTLAND BENTONrTE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEli PACK-if a' liciitile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. 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 DRILLING LOG attach'additionafsheets ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn soikck e> rain size etc.
0.0 It. 1.0 ft. CONCRETE
4.Date Well(s)Completed: 06/20/22 Well ID# MW-6 1.0 10.0 It. RED SILTY CLAY
Sa.Well Location: 10.0 ff 20.0 `'
BROWN SILTY CLAY
CIRCLE K- 2723843 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4470 NC - 87 SANFORD 27332 ft. ft.
Physical Address,City,and Zip ft. ft.
LEE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-2.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certification-
350 25' 27.38" N 790 07' 15.77" W ���� 07/11/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor _y
By signing this form,I hereby certify that the well(s)was were`cansti aic rlTnlacdbr mr7 iced
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Sta4dar 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. A IJ r �/� 2 0 2 Z
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page!to,provid9afliti t�6e;we i
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach add necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20.0 (ft')
For multiple wells list all depths ifdiffereni(example-3@200'and 2@1000 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
lfwater level is above casing,use
11.Borehole diameter: 8.0 (in.) 24b.For Injection Wells:Copy to IDWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER I
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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: i
13b.Disinfection type: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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