GW1-2022-10855_Well Construction - GW1_20221228

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NORTH CAROLINA
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WELL CONSTRUCTION RECORD (GW-1 )
EnvfronmertmfQua(Iry
Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
GW1-2022-10855
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
COREY W GAMWELL [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........ ......... ........... ... ......... ..... .... ......... ......... ......... ......... ......... .........
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
3027 A COREY GAMWELL GROUND ZERO ENVIRONMENTAL
FIELD SERVICES
2.Well Construction Permit#:
......................
WM0401415
List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County,
etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Non-Water Supply Well* Monitoring
Recovery
4.Date well was completed and ID#
......... ......... ......... ......... ..... .........
Date Well Completed* Well ID# Well Yield
12/16/2022 GW1-3 (gallons per minute)"

5.Well Location
Facility/Owner Name*
Not Known Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Stokes
Physical Address* Street Address
1071 and 1075 North Main Street
Address Line 2
City State/Province/Region
Walnut Cove NC
Postal/Zip Code Country
27052 Stokes
Latitude* 36.3123906000 Longitude*-80.1395382000
Decimal degrees Decimal degrees
......... ......... ......... ..... ......... ......... ......... ......... ..... .........
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled: 3
9.Total well depth below land surface: (ft.)
1@25',1@26',1@23' 9a.What is the depth of the casing from ground
surface?
For multiple wells list all depths if different
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
UNK 1.75
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
14.WATER BEARING/FRACTURE ZONES
From To Description
19 26 wet sand and silt
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches

17.SCREEN
From To Diameter Thickness Material
22.00 26.00 0.75 Stainless Steel
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 25.00 sand,silt and clay.wet at 19 ft
in feet in feet
21. Remarks
Collect three water samples with Direct Push Technology.All tooling and well construction materials were removed from
the ground immediately after sampling. Each sample location was abandoned with a bentonite slurry and 3/8 chips with a
cold patch cap.The property owner is not known,the well owner is McDonald's US LLC
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23.Certification
GU/Gj
Signature of Certified Well Contractor