GW1-2022-08394_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
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DAVID HALL 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name j
ft. ft. [
A - 4459 it. ft.
NC Well Contractor Certification Number 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(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernuts•(i.e.U1C,County,State,Variance,etc.) 0.0 ft. 3.0 ft. 2.0 "' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SC
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgticultural ❑Municipal/Public 3.0 f" 13.0 f" 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
❑irrl ation OWells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 1.0 ft PORTLANDaENTONrrE SLURRY
OMonitoring ❑Recovery
Injection Well: ft. f[.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licabte
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 2.0 ft- 13.0 f' 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,soil/rock e, rain size,etc.
0.0 ft- 5.0 ft' SAND/GRAVEL
4.Date Well(s)Completed: 08/09/22 Well ID# MW-2 5.0 ft- 13.0 ft' SANDY CLAY
5a.Well Location: ft. ft I :,Y ; tt °-•• ` `4.7 F u
ARNOLDS GROCERYft. ft. AUG 2Facility/Owner Name Facility ID#(if applicable) ./ -,
407 US 15-501 CARTHAGE 28327 f'_ ft. lnfcfirati2 Urg
Physical Address,City,and Zip ft. ft. iL:1 i.Z1 tiOC.
MOORE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-.1.0-2.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 22' 39.14" N 790 17' 20.16" W 08/16/22
6.Is(are)the well(s): 09Permanent or ❑Temporary Signature of Certified Well Contractor, Date
By signing this Jbrn4/hereby certify dial the[Pell([)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or ONO 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cow
/f this is a repair,.i/l out known ire//construction infbrnmtion and explain the nature oJ'die of this record has been provided to the ivell owner.
repair under 921 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 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: 13.0 (ft.)
Fir multiple wells list all depths ifdii ferem(example-J cil 00'and 1@100') Submit this GW-1 within 30 days Of well completion per the following:
9.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-16I7
I%crater level is above casing,use"+" I
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC` 2'7699-1636
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 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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