GW1-2022-07920_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
Well Contractor Name FROM fr. ft.TO DESCRIPTION
A - 4121 i
ft. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased;wells OR L INER,if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER
TxIC14VESS MATERIAL
0.0 ft• 20.0 ft- 1 6.0 in. SCH 40 PVC
Company Name
•16.INNER CASING OR TUBING eothermal closed-166
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- 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 I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 fr. 30.0 ft' 2.0 'n` .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 7T8.GROUT
01tri ation ❑WelIs>100000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 18.0 ft' PORTLAND BENTONITE SLURRY
MMonitoring ❑Recovery 0.0 ft- 20.0 IL PORTLANDBENTONTEE SLURRY
Injection Well:
fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable ..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 23.0 fit- 30.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control fr. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets'if neressa" __
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,eta
0.0 ft. 1.0 fr• ASPHALT/GRAVEL
4.Date Well(s)Completed: 06/10/22 Well ID#_ DW-1 1.0 ft- 5.0 ft' BROWN CLAY
5a.Well Location: 5.0 ft- 10.0 ft' WHITE/GRAY CLAY
QUICK PICK - 7 10.0 ft- 16.0 fc• BROWN -a. _ 91
Facility/Owner Name Facility ID#(ifapplicable) 16.0 ft- 30.0 ft- ROC. a
408 EAST SALISBURY STREET ASHEBORO 27203 ft. ft.
Physical Address,City,and Zip ft. ft.
RANDOLPH ,2I REMARKS,
In atinn Pr. r=w Uftt1
County Parcel Identification No.(PIN)
BENTONITE SEAL-18.0-23.0 FEET D1=1Q/B0G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
350 42' 22.92" N 790 48' 24.07" W 10611A 06/17/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the ivell(s)was(were)constructed in accordance ivilh
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,Jill out known well construction information and explain the nature of the ofthis record has been provided to the rhell owner.
repair under 921 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only l 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.)
l�or multiple wells list all depths ifdifferent(example-3@200'and 211 100') Submit this GW-1 within 30 days of well completion per the following:
18.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
l0.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: 6.0/10.0 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR
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
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
S
13b.Disinfection type: Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018