GW1-2022-03241_Well Construction - GW1_20220311

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
VINCE FEDERLE 14.WATER ZONES i l
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3552 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. fr. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permils(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): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tr. ft. in.2.0 12.0 2.0 :010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 1.0 ft' PORTLANDBENTONITE SLURRY
(EMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage 1.5 ft- 12.0 fr' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control fr. 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(color,hardness,soilhock type,gnain sin,etc.
0.0 ft. 1.0 ft- ASPHALT/GRAVEL
4.Date Well(s)Completed: 10/1 8/21 Well ID# MW-6 1.0 ft- 12.0 ft• GRAY SILTY SANDY CLAY
5a.Well Location: ft. ft.
DELUXE CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. IAIAD
- -
2223 NORTH MAIN STREET TARBORO 27886 ft. ft. 9
Physical Address,City,and Zip
fr. fr.
EDGECOMBE 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL- 1.0-1.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell 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): 29Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing dtis form,I hereby certify that the mell(s)uvas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fil/out known well construction h formation and explain the nature of the of this record has been provided to the well owner.
repair under t:21 remarks section or an the back of lhis 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 necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12.0 (ft.)
For ntulliple arells list al/depdts if different(example-3 OO'ond 2ae100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 5•0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
!f n eater level is above casing,use"4 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: 8.0 (in,)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water SunDIY 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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018