GW1-2022-08299_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONEs._:i
Well Contractor Name FROM TO I DESCRIPTION
A - 2581 ft. ft.
ft. % ,
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells:OR LWER ifa licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loo' ' '
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction perarits(i.e.UIC,County,Stale,Variance,etc.) 0.0 ft. 5.0 ft. 2.0 1D SCH 40 PVC
3.Well Use(check well use): ft. % in.
Water Supply Well: ;b7.-SCREEN..:_, -..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft• 15.0 ft• 2.0 i- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) `18..GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2.0 ft' PORTLAND BENTONrrE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
`19.SAND/GRAVEL PACK ifa Iicable'
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3.0 It- 15.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING I:OG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltruck type,grain size,etc.
0.0 ft- 7.0 ft- GRAY SILTY SANDY CLAY
4.Date Wells)Completed: 04/18/22 Well ID# MW-43 7.0 ft. 15.0 % BROWN PWR
Sa.Well Location:
ft. ft.
JFD CHANNEL MASTER ft. ft.
FadliqlOncr Name Facility ID#(if applicable) ft. - ft. -
620 WEST INDUSTRY DRIVE OXFORD 27565 ft. ft.
Physical Address,City,and Zip ft. ft.
GRANVILLE 21.REMARKS��­.
County Parcel Identification No.(PIN)
BENTONIfE SEAL-2.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36e 17' 59.48" N 78e 36' 32.12" W ,,ljl+.r
. 04/28/22
6.Is(are)the well(s): 19Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing dris form,I hereby certify that the well(s)was(were)constructed in accordance tivith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
o this record has been provided to the well owner.
If this is a repair,fill our known well construction information and explain the nature ojthe f P ®�
repair under#21 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 constructioninfo
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ove1'in Remarks Box).You may also attachiadd�iiion�pageif necssary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15.0 (ft-)
For multiple wells list all depths ifdierent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
3.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
If ivoter 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: 6.0 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
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 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018