GW1-2023-00837_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
DAVID HALL `14.WATERZONES
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DESCRIPTION
Well Contractor Name V t+°"
;jam' .�t� ft.
A - 4459 4 ��a � 3�� fr.
NC Well Contractor Certification Number I p A I 1 q f19'! 15 OUTER CASING for multi-cased welts OR.LINER'if a"lieable
GEOLOGIC EXPLORATION •J hiN 1 t� l.1LJ FROM TO DIAMETER THICKNESS MATERIAL
r a _ MT ft. ft. i in.
Company Name lRtt7n1 :t'.1
Dt. � 0ty t6:'INNER CASING OR TUBING 'eothtrmal closed=too' °':, -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 fr. 5.0 ft. 2.0 'n' SCH 40 PVC
3.Well Use(check well use): ft. fr. in.
Water Supply Well: '17.SCREEN . .11
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 5.0 ft. 20.0 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) IS:-GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO .. MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 ft' PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery fr. fr.
Injection Well:
fr. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19:SANDlGRAVEL PACK,if.a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 4.0 ft. 20.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer '20.,DRILLINGTOG attacli additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.
0.0 ft- 0.5 ft. ASPHALT
4.Date Well(s)Completed: 01/09/23 Well ID# MW-12 0.5 ft. 1.0 ft. GRAVEL
5a.Well Location: 1.0 ff' 20.0 ff- SILTY CLAY
CROSSROADS CENTER- C fr. fr.
Facility/Owner Name _ Facility ID#(if applicable) ft. ft. !
134 ARNOLD ROAD LEXINGTON 27295 ft. fr.
Physical Address,City,and Zip ft. ft.
DAVIDSON .21.REMARKS-,',w
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 52' 02.48" N 800 15' 02.58" W �� 01/10/23
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was 6were)constructed in accordance wilt
7.Is this a repair to an existing well: ❑Yes or MNo I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under 421 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 1 GW-1 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: 20.0
For multiple wells list all depths ifeli ferent(example-3 a 200'and 2 a I00') Submit this GW-1 within 30 days,of well completion per the following:
]0.Static water level below top of casing 12.0 (ft) 24a. For All Wells: Original form!to Division of Water Resources (DWR),
110.St level is above casing,use op Information Processing Unit,1617 rMSC,Raleigh,NC 27699-1617
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 SupDty and Openll
-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 producinglover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh INC 27699-1611
13a.Yield(gpm) Method of test: I
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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