GW1-2022-03253_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. I
A - 2581
ft. ft.
NC Well Contractor Certification Number
'15.OUTER CASING for multi-casediwells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. ��
Company Name '.
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) 0.0 ft. 20.0 ff. 2.0 i"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 ft' 40.0 ft' 2.0 in.,
n. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wel Is>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 10.0 ft' PORTLANDBENTONrrE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a IicSble
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 18.0 ft. 40.0 It. 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,sail/rock type,gmin sin,etc.
0.0 ft. 9.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 02/01/22 Well ID# MW-6 9.0 ft. 22.0 ft. TAN/WHITE PWR
5a.Well Location: 22.0 It. 30.0 fl' BROWN SILTY SAND
A-1 EXPRESS 30.0 ft- 40.0 ft. TAN SILTY SAND
Facility/Owner Name Facility IDt!(if applicable)
ft. ft.
603 EAST MAIN STREET LINCOLNTON 28092
Physical Address,City,and Zip ft. ft.
LINCOLN 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE 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 �}�,,,,�
02/14/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor ! Date
By signing this form,I hereby verb thai the ivell(s)was(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,fill out known well construction information and explain the nature of the oJ'this record has been provided to the ivell owner.
repair under 921 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 1 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 (ft.)
1--or multiple wells list all depths ifdii ferent(example-3 rci 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),
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
11.Borehole diameter: 6.0 (in,) 24b. For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 12*9-1636
12.Well construction method: AIR
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 ment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinE 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 Resource i s Revised 6-6-2018
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