GW1-2022-03254_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS I,LWATERZONES' 17
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581 e. a.
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. ft.
in.
Company Name
16.INNER CASING OR TUBING eothermal closed-lob
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counl,Stale,Variance,etc) 0.0 ft- 20.0 ft. 2.0 t" SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER:' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 D. 40.0 ft' 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
❑lrri atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 rt. 10.0 ft. PORTLANDaENTONITE SLURRY
MMonitoring ❑Recovery
Injection Well:
ft. ft.
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage 18.0 ft. 40.0 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 TO DESCRIPTION color,hardness,soil/rack type,grain size,etc.
0.0 ft. 9.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 02/01/22 Well ID# MW-5 9.0 rt. 21.0 ft. TAN/WHITE PWR
5a.Well Location: 21.0 ft' 32.0 ft' BROWN SILTY SAND
A-1 EXPRESS 32.0 ft- 40.0 ft. TAN SILTY SAND
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAR ?
603 EAST MAIN STREET LINCOLNTON 28092 ft. ft.
Physical Address,City,and Zip It. 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 lit/long is sufficient) 22.Certification:
3SO 28' 26.61" N 810 14' S7.72" W 0-y _
02/14/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified 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 MNo 15A NCAC 02C.0100 or ISA 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 of this record has been provided to the ivell owner.
repair under 921 remarks section or on the back of This forte
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-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: 40.0 (ft)
For multiple wells list all depths ifdierent(example-3 r@200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 30.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617`IMSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i.
IL Borehole diameter: 6.0 (in,) 24b. For Injection Wells:Copy to I DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR I24c.For Water Supply and Opeo-Loop 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 producini over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Font G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018