GW1-2022-03252_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. f
A - 2581
ft. rr.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased'wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER ,, THICKNESS MATERIAL
rt. a. in.Company Name -
I&INNER CASING OR TUBING eotliermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS .MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) 0.0 rf 20.0 rt. 2.0 '"' SCH 40 PVC
3.Well Use(check well use): ft. tt. in.
Water Supply Well: FROM
SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 ft. 40.0 ft' 2.0 in.
' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/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 ft' 10.0 ft- PORTLANDaENTON[TE SLURRY
29Monitoring ❑Recovery ft. ft.
Injection Well:
rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 18.0 ft. 40.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑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,soil/rock e, rain size etc.
0.0 rt• 7.0 rt' RED SILTY CLAY
4.Date Well(s)Completed: 02/01/22 Well1D# MW-7 7.0 rt• 330 r`' TAN/WHITE PWR
5a.Well Location: 33.0 ft' 40.0 f`' BROWN SILTY SAND
A-1 EXPRESS
Facility/Owner Name Facility ID#(ifapplicable) ft. ft f
603 EAST MAIN STREET LINCOLNTON 28092 rt. rt. M
Physical Address,City,and Zip
a. ft
LINCOLN 21.REMARKS
County Parcel Identification No.(PIN) BENTONUE SEAL 10.0-18.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 28' 26.61" N 810 14' 57.72" W �/�'fti,,. r-- 02/14/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,1 hereby certify thai;the trel/(s)tras(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
/Jlhis is a repair,fill out knoum Ire//construction information and explain the nature of the of this record has been provided to the use//owner.
repair under#21 remarks section or on the back oJ'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: 40'0
For multiple bells list all depths ifdii ferew(example-3(a 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
30.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f/'rooter level is above casing,use
11.Borehole diameter: 6.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
�
12.Well construction method: AIR 24c.For Water Supply and Open l-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depart I 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:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018