GW1-2022-07838_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL WATER ZONES
Well Contractor Name FROM IPTI TO DESCRON
ft. ft. � '
A - 4459 ft. ft.
NC Well Contractor Certification Number 45.OUTER CASING for multi-cased`wells OR LINER.if a 'licabld
GEOLOGIC EXPLORATION FROM I TO DIAMETER THICKNESS MATERIAL
ft. ft. � is
Company Name
16,INNER CASING OR TUBING %eothermat 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 fi- 25.0 ft. 2.0 1°' 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 ft' 30.0 ft' 2.0 '"' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 7f8 GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 20.0 ft' PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.'SAND/GRAVEL PACK(if a`'licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 23.0 ft. 30.0 It' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGrLOG Wtitch additional sheets,ifnecessa ,„
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type rain size,etc.
0.0 It. 30.0 ft. SILTY SANDY CLAY
4.Date Well(s)Completed: 05/23/22 Well ID# AS-2 ft. ft.
5a.Well Location: ft. ft.
PEGGYS QUICK MART ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5403 FLOWER HILL ROAD KENLY 27542 ft. ft.
Physical Address,City,and Zip ft. ft.
JOHNSTON 21 REMARK& ...
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]at/long is sufficient) 22.Certification:
350 40' 41.90" N 780 10' 10.73" W 421_�
6.Is(are)the well(s): IBPermanent or ❑Temporary Signature of Certified Well Contractor a L .,-.P ,ate
By signing this form,I hereby certify that the wells)w (,tiy�re.0r�tru§t accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or/SA NCAC 01C.0200 Wel s� rormBl and that a copy
Ifilds 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.
repair under#21 remarks section or on the back ofthis form. y D1`Ylft^i.:�
23.Site diagram or additional well dew ,�t�,� Ita
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide aAd9�ri�blttdtKdlill'construction 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: 30.0 (ft.)
For multiple wells list all depths V'di,(jerent(example-3 a 00'and 1 rei 100') Submit this GW-1 within 30 days of well completion per the following:
DRY 24a. For All Wells: Original fom to Division of Water Resources (DWR),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water lave!is above casing,use"+" I
11.Borehole diameter: 8.0 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
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 producingllover 100,000 GPD:Copy to DWR,CCPCUA
13s.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
S
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018