GW1-2022-03237_Well Construction - GW1_20220311

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
VINCE FEDERLE 14.WATER ZONES
Well Contractor Nam FROM e ft. TO ft. DESCRIPTION�
A - 3552
rr. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
a. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal 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- 2.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 2.0 ft 12.0 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) 18.GROUT
01rr1 ation OWells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 1.0 ft' PORTtAND BENTONnE SLURRY
1!9Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 1.5 ft. 12.0 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#21 Remarks) FROM TO DESCRIPTION rotor,hardness,soil/rock type,gnin size,etc.
0.0 ft. 1.0 ft. GRAVEL
4.Date Well(s)Completed: 10/21/21 Well ID# MW-10 1.0 ft. 12.0 ft. GRAY SILTY SANDY CLAY
Sa.Well Location:
DELUXE CLEANERS ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
WIAK I It LULL
2223 NORTH MAIN STREET TARBORO 27886
Physical Address,City,and Zip ft. ft.
EDGECOMBE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 1.0-1.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
350 54' 50.91" N 770 32' 41.55" W 10/29/21
6.Is(are)the well(s): ITPermanent or ❑Temporary Signature of Certified Well Contractor Date
By.signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 19No 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
#this is a repair,Jill out known well construction information and explain the nature of the oJ7his record has been provided to the uvel/owner.
repair under F21 remarks section or on the back of'this Jornt.
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: 12.0 (ft.)
multiple wells list al/depths it"diJJerent(example-3ca 200'and 2@/00') Submit this GW-1 within 30 days of well completion per the following:
lobr
10.Static water level below top of casing: 5.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If venter level is above casing,use"+"
Infonnation Processing Unit,1617iMSC,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 j
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
I
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 2 7699-1 6 1 1
13b.Disinfection type: Amount:
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018