GW1--07209_Well Construction - GW1_20231108

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information: i
Connor Cordingley ,14.WATER ZONES ' '
Well Contractor Name FROM , TO DESCRIPTION
20 ft. 30 ft, Surf ial
4568 A -
ft. ft. I,
NC Well Contractor Certification Number -:,15::OUTER CASING(forruulti-cased`wells)OR LINER(if ap licable)
A.C. Schultes of Carolina, Inc. _FROM _TO DIAMETER THICKNESS 1 MATERIAL
ft. ft. 1 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 permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 20 ft• 4.5 I in' SDR-17 PVC
3.Well Use(check well use): 30 ft. 35 ft• 4 In' SDR-17 PVC
Water Supply Well: 17.SCREEN
FROM TO DIAMEILR SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 20 ft. 30 ft' 4 in. .20 SCH40 304SS
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. '• _i ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .,
- S- ' - .
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 15 ft. #2 ' TREMMIE
OMonitoring ❑Recovery ft. ft. -
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if keplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 15 ft. 35 ft. #2 TREMMIE
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. rt. SEE ATTACHED
4.Date Well(s)Completed: 11/2/23 Well ID# U48V1 ft. ft. i -f T 7-AAl1
5a.Well Location: ft. ft. • z'm" ..', ts,k..n,L
NCDEQ- DWR ft. ft. i NOV 0 8 2023
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Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft. `
Dt;`a=..1•75::=1-Y
ft. ft.
Physical Address,City,and Zip
Scotland 21..REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1aUlong is sufficient) 22.Certification: I /
N W i .l / / 7 /•�3
� sss J( li
6.Is(are)the well(s): I lPermanent or ❑Temporary Sig f ere actor I Date
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By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or t`JNo 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 Over'in.Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) i
For multiple wells list all depths if different(example-3@200'and 2@l00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 17 (ft-) 24a. For All Wells: Original fonri to Division of Water Resources (DWR),
If water level is above casing,use"+"If Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Mud Rotary I,
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
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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 27699-1611 -
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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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Formation Description for Well Record
C-1407 NCDENR—Lumber River State Park—U48V1
0—20 Pea Gravel, Coarse Sand
20—30 Coarse Sand,Trace of Clay
30—35 Orange Clay
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