GW1-2022-08302_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES,
Well Contractor Name FROM TO I DESCRIPTION
ft. ft.
A - 2581
ft. ft. �
NC Well Contractor Certification Number 15.OUTER CASING for mrdtt-cased we
OR LINER ifa licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING' eothermal closed-loon)
2.Well Construction Permit#: FROM To I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0,0 ft- 68.0 ft- 2.0 1° 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 68.0 ft• 78.0 ft. 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
❑Irri anon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 5.0 ft. PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL IPACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 66.0 ft' 78.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach addition d'sheets if necessary)" -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft• 13.0 ft• GRAY SILTY SANDY CLAY
4.Date Well(s)Completed: 04/19/22 Wel1ID# MW-24D 13.0 fi- 53.0 ft- BROWN PWR
5a.Well Location: 53.0 ft. 78.0 ft• ROCK
JFD CHANNEL MASTER ft. ft
Facility/Owner 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) BENTONITE SEAL-5.0-66.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
360 17' 59.48" N 780 36' 32.12" W
04/28/22
6.Is(are)the well(s): @§Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the rvell(s)ivas(were)constructed in accordance with
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
If this is a repair,fill out known ivell construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form, n '
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 Over'in Remarks Box).You may also attach additio 2 2 pal.papesJf ecessary.
drilled: % L��
24.SUBMITTAL INSTRUCTIONS MAY
9.Total well depth below land surface: 78.0 (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:
10.Static water level below top of casing: 36.0 (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: 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 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018