GW1-2022-03250_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) i For Internal Use Only:
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1.Well Contractor Information: 1
NICHOLAS HAYES -14.WATER ZONES s
Well Contractor Name FROM TO DESCRIPTIONft. ft. ! ,
A - 4121 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased welts OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
fr. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.U1C.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 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft 20.0 fl' 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_
❑Irri ation ❑Wel Is> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft 5.0 ft' PORTLANDBENTONITE SLURRY
MMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa lii:able
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage 8.0 ft- 20.0 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 I TO DESCRIPTION color,hardness,soilhnck type,grain size,etc.
0.0 ft 20.0 rr' RED SANDY CLAY
4.Date Well(s)Completed: 02/24/22 Well ID# MW-16 ft. ft.
Sa.Well Location:
rt. rr.
SPEEDWAY - 8299MAN I
Facility/Owner Name Facility IDO(ifapplicable)
291 NC HIGHWAY 42 CLAYTON 27527
rr.
Physical Address,City,and Zip ft. '
JOHNSTON 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-•5.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hat/long is sufficient) 22.Certification:
350 38' 22.88" N 780 26' 24.59" W 02/25/22
6.Is(are)the well(s): f9Permanent or ❑Temporary Signature ofCertified Well Contractor Date
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By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!9No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction infbrntation and explain the nature of dte of this record has been provided to fire ii,ell owner.
repair under 921 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over' Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20•0 (ft.)
/,or multiple wells list all depths ifd ereni(example-3 a 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 14.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
if water level is above caring,use
Information Processing Unit,16171MSC,Raleigh,NC 27699-1617
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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 depart)ment 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 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S