GW1-2021-00746_Well Construction - GW1_20210401

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
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1.Well Contractor Information:
BRIAN THOMAS P. 14.WATER ZONES i
Well Contractor Name FROM 1 TO DESCRIPTION
A - 2581 ft. ft.
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pY2021 ft. fr.
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NC Well Connector Certification Number 'It 15.OUTER CASING for mulfi-cased wells OR LINERlivable
GEOLOGIC EXPLORATION arD`Csg1f�� FROM TO DIA NIETER THICKNESS MATERIAL
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v et 0.0 f1. 55.0 ft. 6.0 SCH 40 PVC
Company Name ,y t �V Y 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertnils(i.e.U/C.Count}',State.Variance,etc) 0.0 ft. 129.0 ft. 2.0 in' SCH 40 PVC
3.Well Use(check well use): in:
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Water Supply Well: 17.SCREEN t
FROM TO DIAMETER !SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 129 0 ft. 144.0 1" 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
❑lrrl atlon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 117.0 ft- PORTLAND BENTONRE SLURRY
MMonitoring ❑Recovery 0.0 ft. 55.0 ft- PORTLANDBENTONITE SLURRY
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remcdiation
19.SAND/GRAVEL PACK ifa tlicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 127.0 ft. 145.0 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 421 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type.grain size,etc.
0.0 ft. 8.0 ft. BROWN SILTY SANDY CLAY
4.Date Well(s)Completed: 03/1 9/21 Well ID# MW-2D 8.0 ft. 31.0 ft. RED SILTY SAND
Sa.Well Location: 31.0 ft' 50.0 ft. I PWR
CHARAH - BRICKHAVEN 50.0 ft. 145.0 ft. ROCK
Facility/Owner Name Facility[DO(ifapplicable) ft. ft. I
1271 MONCURE FLATWOOD ROAD MONCURE 27559 ft. ft.
Physical Address.City,and Zip
rr. ft.
CHATHAM 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 117.0-127.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
350 56' 07.87" N 790 01' 83.71" W � 0'r-- 03/24/21
6.Blare)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing ihis form,1 hereby certlfi,that the u•efl(s)was(were)constructer)in acc•ordonce udth
7.Is this a repair to an existing well: ❑Yes or p(Vo 15A NCA('02C.0100 or 15A N(AC 02C.0200 Well Conrirucrion,5'mndnrdr and that a copy
!(this is a repair.(ill out known tire//construction injorinalion and explain the nature ofthe ofihis record has been provided to the well inner.
repair under=21 remarks section or on the back ofthis•form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction into
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You tnav also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS';
9.Total well depth below land surface: 144.0 (ft.)
1-or inu/tip/e sve//s list a//depths Y'dV creni(example-3@200'and 2 a 00') Submit this GW-1 within 30 days of well completion per the following:
10. 109.0 24a. For All Wells: Original form!to Division of Water Resources (DWR).
Static water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,,Raleigh,NC 27699-1617
' lf/'vtuer Jerel is above caring,use"-" II
11.Borehole diameter: 6.0/10.0 (in) 24b. For Infection Wells:Copy to D`WR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699,-1636
12.Well construction method: AIR 24c.For Water Supplv 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ov'r 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.field(gpm) Method of test:
13b.Disinfection type: Amount: f
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Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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