GW1--05861_Well Construction - GW1_20230912

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeovany Gutierrez Bautista .14.WATER ZONES' . P•"+ .
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4125-A ft. ' ft. ' I
NC Well Contractor Certification Number 15.OUTER CASING,(for multi=cased wells)OR LINER(if ap licable) .
A.C. Schultes of Carolina, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16:INNER CASING.ORTUBING(geothermal closed=loop) -c . .
2.Well Construction Permit#: FROM , TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft' ft. in.
Water Supply Well: 17.SCREEN. -
FROM _ TO DIAMETER SLOT SIZE THICKNESS MATERIAL
IJAgricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
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❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROU " '
_❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. j
❑Monitoring ,,,...es,+;y -'t� ec very ft. ft.
Injection Well: ,,,,,
c,..,J', k„otw i..., ft. ft.
❑Aquifer Recharge 202POGroundwater Remediation
❑A uifer Storage and R yy .19.SAND/GRAVEL-PACK(if applicable)
q g § ryl Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ,, Effilii fpvater Drainage ft. ft.
❑Experimental Te idlio' ( 'v .3�` ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) - - r
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
100 ft* 110 ft• Clay,Sand,Some Shell
4.Date Well(s)Completed: 8/22/23 Well ID# 2 110 ft 120 ft Clay, and,Trace of Shell
5a.Well Location: 120 ft 180 ft' Sand,,Clay
Butterball Feed Mill 180 ft 190 ft Silty Sand,Clay
Facility/Owner Name Facility ID#(if applicable) 190 ft 210 ft. Clay,Sand
5604 Hwy 24, Turkey, NC _ 210 ft. 230 ft Clay,Trace of Sand
Physical Address,City,and Zip 230 ft 240 ft. Blue Sandy Clay,Some Gray Clay
Sampson 21.REMARKS
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County Parcel Identification No.(PIN) I'
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: I
N W i I n -a3
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6.Is(are)the well(s): IJPermanent or ❑Temporary lure. . actor I, Date
igning this form,I hereby cert J that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this 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 Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all depths if different(example-3@200'and 2@I00') Submit this GW-1 within 30 days'of well completion per the following:
10.Static water level below top of casing: 52.25 ,,, s 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" )
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 17 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 24c.For Water Supply and OpenlLoop 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.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
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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