GW1-2022-08378_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER'ZONES '
FROM TO DESCRIPTION
Well Contractor Name
ft. ft. '
A - 4459 ft. ft.
NC Well Contractor Certification Number R=" y 15.OUTER CASING'for multi-cased wells OR LINER if a licable ,
GEOLOGIC EXPLORATION FROM TO DIAMETER, THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: - ;! Urn, FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC? n-, Iajt, trelc.) 0,0 ft' 10.0 ft. 2.0 rn SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft' 20.0 It' 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 ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 5.0 ft- PORTLAND BENTONrtE SLURRY
IMMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
i 19:SAND/GRAVEL'PACK if applicable)'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 8.0 ff• 20.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
0.0 It. 1.0 ft. SILTY CLAY
4.Date Well(s)Completed: 04/13/22 Well ID# MW-1 7 1.0 ft- 20.0 ft- SANDY SILT
ft. ft.
5a.Well Location:
SAAB ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
608 EAST MCNEILL STREET LILLINGTON 27546 ft. ft.
Physical Address,City,and Zip ft. ft.
HARN ETT '21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-5.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification:
35e 23' 25.32" N 780 48' 32.62" W �✓ �' 04/25/22
6.Is(are)the well(s)• TPermanent or []Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert Jy that the rvell(s)ivas(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or INNo 1 SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out knoivn well construction information and explain the nature ofthe oflhis 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 Ovet'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20'0 (ft.)
For multiple wells list all depths!fd fferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
0.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
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
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of.Water Resources Revised 6-6-2018