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WELL CONSTRUCTION RECORD(GW-1) ' For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES t
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4475 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if appIlicable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS I MATERIAL
ft. ft. I 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.) 0.0 ft' 10.0 ft 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM. TO DIAMETER _ SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft' 20.0 ft* 2.0 1°' .010 SCH 40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. •
0 Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
0 Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft 5.0 ft PORTLANO BENTONITE SLURRY
fEMonitoring ❑Recovery ft. ft.
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD •
❑Aquifer Test ❑Stormwater Drainage 8.0 ft 20.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sine,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft. 1.0 ft• TOPSOIL
4.Date Well(s)Completed: 02/12/22 Well ID# MW-1 1.0 ft' 10.0 ft* BROWN SILTY CLAY
5a.Well Location: 10.0 ft' 20.0 ft' TAN SILTY SAND
CIRCLE K - 2723019 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAR 1 i. 702''
400 ERWIN ROAD DUNN 28334 ft. ft.
ft. ft.
Physical Address,City,and Zip
HARNETT 21.REMARKS •
County Parcel Identification No.(PIN) BENTONITE'SEAL-5.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35° 18' 56.38" N 78° 37' 35.08" W K%
4, 02/18/22
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or fENo 15A NCAC 02C.0100 or ISA 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 42/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 I 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 (ft.)
For multiple wells list all depths if different(example-3@200'and 2 n 100') Submit this GW-1 within 30 days of well completion per the following:
15.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water Ierel is above casing,use"+"
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 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 2 7699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Fono GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018