GW1-2022-08266_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.;WATER,ZONE&
Well Contractor Name FROM TO DESCRIMON
ft, ft.
A - 4459 _
g� ft. ft.
NC Well Contractor Certification Number ��„ N 1
ti..>. 3 6� °�ISi.OD'PER CASING for mulh=cased�wells`OR LINER'(if a `licable F-
GEOLOGIC EXPLORATION FROM I TO DIAMETER T THICKNESS MATERIAL
ft. ft. in.
Company Name MAY
:16.'INNER,CASING OR TUBING g ibitheimal closed-loo
2.Well Construction Permit#: _ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(I.e.UIC Afjt�b`i)ttd'Ila San -r�{y�n 0.0 ft- 14.0 ft- 2.0 1°' SCH 40 PVC
�1.1` .
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM REENTO' DIAMETER SLOT SIZE THICKNESS. MATERIAL
❑Agricultural ❑Municipal/Public 14.0 ft- 24.0 ft' 2.0 1n. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft, in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 9.0 ft' PORTLANDBENTONITE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
4�19.SAND/GRAVEL,PACK iCa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 12.0 ft• 24.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sIbeets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillmck type,grain sae,eta
0.0 fL 24.0 ft- TAN SAND
4.Date Well(s)Completed: 02/23/22 Well ID# MW-4R ft. ft.
5a.Well Location: ft. ft.
MCOLF OAK GROVE ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1380 OAK GROVE ROAD TRENTON 28585 ft. ft.
Physical Address,City,and Zip ft. ft
O N ES :21'.REMARKS'-
County Parcel Identification No.(PIN) BENTONIfE SEAL-9.0-12.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-
35° 02' 01.22" N 770 15' 18.47" W 4�2 03/09/22
6.Is(are)the well(s): 19Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [END 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Iftlris is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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 I GW-I 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: 24.0 (ft.)
For multiple wells list all depths ifeli ferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
15.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+"
f Static water level below top of casing: (ft.) 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 roducin over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018