GW1-2022-07840_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
DAVID HALL 14:WATERZONEs
Well Contractor Name FROM TO DESCRIPTION
fr. ft. `
A - 4459 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING'for multi-cased wells OR-LINER tfa licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in.
Company Name
16.INNER CASING OR TUBING 'eothermal,closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS _ MATERIAL
Listall applicable well constructionpermits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 25.0 ft- 2.0 I - SCH 40 PVC
3.Well Use(check well use): ft. fr. i in.
Water Supply Well: 17.SCREEN A i
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25,0 ft• 30.0 ft' 2.0 ini .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared)
AS.GROUT
❑lf i ation ❑Wells>100,000 GPD, FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 20.0 ft' PORTLANDaENTONRE SLURRY
25Monitoring ❑Recovery ft. ft.
Injection Well: ft. tr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACT{(if a "licable`
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 23.0 ft' 30.0 fr• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional'sheets if'necessa a%, `
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn soil/rock type,grain size,etc.
0.0 fr• 30.0 It- SILTY SANDY CLAY
4.Date Well(s)Completed: 05/24/22 Well ID# AS-3 ft. ft.
Sa.Well Location:
rt. 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, ft.
,and Zip I
JOHNSTON 21•REMARKS,
County Parcel Identification No.(PIN) BENTONIfE SEAL-20.0-23.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: )
35o 40' 41.90" N 78o 10' 10.73" W ✓G � -�
06/15/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that thew w4s,(wereJ�+sirucI once with
7.Is this a repair to an existing well: ❑Yes or �No !SA NCAC 02C.0/00 or/SA NCAC 01C.02 WellGosrruffl+on Sta,as d t ar a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well oiv err• ^ a'§a• '
repair under 921 remarks section or on the back ofthis form.
23.Site diagram or additional well(details: ( 9, 2�027
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide dgitio'J 1 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also a"ch Vdi>�on sli acessary.
drilled: Mir tPfi3.«%l L 4
24.SUBMITTAL INSTRUCTIONS rJ1dG21►�C1(3
9.Total well depth below land surface: 30.0 (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 2 rr/00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: DRY (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+•' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in,) 24b.For Injection Wells:Copy to 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 producingover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Ralerg ,'NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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