GW1-2022-08523_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 DESCRIPTION
ft. ft.
A - 2581
ft. ft.
NC Well Contractor Certification Number 15.OUTER.CASING for mulfi-cased wells OR LiNER if a dicable
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 hell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 fi- 54.0 ff 2.0 t"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Witter Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 54.0 fL 74.0 rL 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
❑frri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 30.0 ft. PORTLANDaENTONITE SLURRY
[OlMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 52.0 I'L 74.0 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,soil/rock type,a,min size,etc.
0.0 ft. 8.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 03/31/22 Well ID# MW-7 8.0 fL 17.0 ft. TAN SILTY SANDY CLAY
5a.Well Location: 17.0 fL 36.0 ft' BROWN SILTY SANDY CLAY
SPENCER MOUNTAIN 36.0 ft. 45.0 ft. PWR
Facility/Owner Name Facility ID#(ifapplicable) 45.0 ft. 74.0 ft. ; ROCK
1368 LOWELL SPENCER MOUNTAIN ROAD GASTONIA 28056 ft. ft.
Physical Address,City,and Zip ft. ft.
GASTON 21.REMARKS
Comity Parcel Identification No.(PIN) BENTONITE SEAL•-30.0-52.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 17' 36.58" N 810 06' 11.52" W � r`-' 04/04/22
6.ls(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing this form,/hereby certify that the ihel/(y)sras(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fill out knolm well construction information and explain the nature of the of this record has been provided to the trell ou ner.
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 we n truction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You Inay also attach additions if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
t p,
eF•10.E¢ n
9.Total well depth below land surface: 74.0 2 2O 22
For multiple trills list all depths ifd/i fereni(example-9 a 100'and 2 a@ (ft.) t��100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 29.0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
/flrater level is above casing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8:0/4.0 (in) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program, ]636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/AIR
24c.For Water Supply and Open-Loon 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.field(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018