GW1-2022-07835_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: E
CARL CARPENTER 14.WATERZONEs a~
Well Contractor Name FROM ft. ft.TO DESCRIPTION
l
A - 4475 '
ft. ft. I /
NC Well Contractor Certification Number 15.OUTER.CASING,for multi-cased wells OR LINER i o licbble ,
GEOLOGIC EXPLORATION FROM To DIAMgR THICKNESS MATERIAL
0.0 f1. 25.0 ft 6.0 j i" SCH 40 PVC
Company Name
16."INNER CASING OR TUBING 'eothermallclosed=too '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) 0.0 ft- 42.0 fi- 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 42.0 ft• 47.0 ft. 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 24.0 ft' PORTtAND,BENTONITE SLURRY
EMonitoring ❑Recovery 0.0 ft. 250 ft' PORTLAND BENTONNE SLURRY
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAV1•;I5°PA'CK tf a'"tic"mile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 40.0 ft• 47.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 10..DRILLING�L0G attbel'a'dditioiiaiiheet"saifiecessa`-K" _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUrock y,grain size etc.
0.0 ft. 1.0 It. CONCRETE
4.Date Well(s)Completed: 06/22/22 well ID# DW-1 1.0 ft. 10.0 ft. RED SILTY CLAY
5a.Well Location: 10.0 ft' 20.0 ft' BROWN SILTY CLAY
CIRCLE K- 2723843 20.0 ft- 40.0 ft. GRAY CLAY
Facility/Owner Name Facility ID#(if applicable) 40.0 ft. 47.0 ft. ? PWR
4470 NC - 87 SANFORD 27332 ft. ft.
Physical Address,City,and Zip ft. ft.
LEE 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-24.0-40.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certification:
350 25' 27.25" N 790 07' 14.76" N n,� --��
07/11/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing lhis jorm,l hereby cerl that the well(s)was
eoslruaEl e¢iiri,acr. IN
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well C ns �l°akAhIPA and Y
!f this is a repair,fill out known well construction information and explain the nature of the ofrhis record has been provided to the well owner.repair under#21 remarks section or on the back of this form. P�J 6 2 ✓ 2ln
'22
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construe•o
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same �.� f� ��
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may alsJ11WW `� p
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 47.0 (ft.)
For multiple wells list all depths if different(example-3@200'and 2 r�r/00) Submit this GW-I within 30 days of well completion per the following:
40.0 24a. For All Wells: Original form to Division of Water Resources (DVIR),
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
12.0/5.875 24b.For Iniection Wells:Copy to,DWR,Underground Injection Control(IUC)
11.Borehole diameter: _(in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/MUD ROTARY
24c.For Water Supply and Open-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018