GW1-2022-08267_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL14 wATERzoNEs::...
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4459RECEIV
E) ft. ft.
NC Well Contractor Certification Number 15:OUTER CASING'foriuulh cased wells'AR LINER it a"'licable"`
GEOLOGIC EXPLORATION MAY 3 0 2022 FROM TO DIAMETER I MATERIAL
ft. ft. in.
Company Name
Inforpii-:0--i f�PC a;�:.';t� Uni• 16.INNER.CASINGOlt ING 'eotikrmal"dosed-loo
2.Well Construction Permit9: r ik6f()f't%(}f; FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft. 17.0 ft- 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17 SCREEN.
Water Supply Well: =
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 17.0 1` 27.0 1" 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18rGROUT,.
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 12.0 ft' PORTIAND BENTONnE SLURRY
I19Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL,PACK if a licable 't
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD J
❑Aquifer Test ❑Stormwater Drainage 15.0 ft' 27.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG attach'additional sheets`ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCREMON color,hardness,soillrock type rain size,etc.
0.0 ft. 27.0 ft TAN SAND
4.Date Well(s)Completed: 02/23/22 shell ID# MW-6R ft. ft.
Sa.Well Location: ft. ft.
MCOLF OAK GROVE ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1380 OAK GROVE ROAD TRENTON 28585 ft. ft.
Physical Address,City,and Zip
ft. ft.
J O N ES a2I?REMARKS.;
County Parcel Identification No.(PIN) BENTONITE SEAL-12.0-15.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-
350 02' 01.22" N 770 15' 18.47" W
��'- 03/09/22
6.Is(are)the well(s): 1EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IENo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovel'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 27.0 (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100D Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 19.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater 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 producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gP m) Method of test: Permit Program,1611 MSC,Raleigh;NC 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018