GW1-2022-03239_Well Construction - GW1_20220311

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
VINCE FEDERLE 14.WATER ZONES l
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 3552
ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Iicable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft.
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.CIIC,County,State,Variance,etc) 0.0 ft. 2.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. fr. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2.0 ft. 12.0 ft. 2.0 1 ' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri atlon ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 1.0 ft' PORTLANOBENTONITE SLURRY
(EMonitoring ❑Recovery tr. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater 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 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gimin sin,etc.
0.0 It. 1.0 ft. GRAVEL
4.Date Well(s)Completed: 10/1 9/21 Well ID# MW-7 1.0 ft. 12.0 ft. GRAY SILTY SANDY CLAY
5a.Well Location:
DELUXE CLEANERS
Facility/Owner Name Facility ID#(ifapplicable)
2223 NORTH MAIN STREET TARBORO 27886 D. fr.
Physical Address,City,and Zip ft. ft. MAR ?
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 lat/long is sufficient) 22.Certification:
350 54' 50.91" N 770 32' 41.55" W 10/29/21
6.Is(are)the well(s): MPermanent or OTemporary Signature ofCertifned Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [ENo I5A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
/f 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 ofthis 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessafy.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12.0 (ft.)
hip/e wells list all depths iJ'dierent(example-3@100'and 1 a 100') Submit this GW-1 within 30 days of well completion per the following:
For mu
5.0 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 level is above casing,use";"
It.Borehole diameter: 8.0 (in,) 24b. For Infection 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-Loon 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 27699-1 61 1
13a.Yield(gpm) Method of test: f
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13b.Disinfection type: Amount:
i
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018