GW1-2022-03311_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4121
ft. ft. i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
tr. a. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permils(i.e.UIC,County,Slate,Variance,etc) 0,0 ft- 10.0 It. 2.0 � in. 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 10.0 ft' 25.0 fL 2.0 In- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. 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 ft. ft.
Injection Well:
ft. ft.
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 8.0 ft- 25.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilhrock type,grain sin,etc.
0.0 ft- 16.0 ft- BROWN SILTY CLAY
4.Date Well(s)Completed: 09/03/21 Well ID# MW-9 16.0 ft- 25.0 ft- BROWN CLAYEY SANDY SILT
5a.Well Location: ft. ft.
FOOD MART - 10 fr. fr.
Facility/Owner Name Facility7D#(ifapplicable) ft. ft. MAR 1 ?
1150 VIRGILINA ROAD ROXBORO 27573 f. ft. n"
Physical Address,City,and Zip ft. ft.
PERSON 21.REMARKS'
County Parcel Identification No.(PIN) BENTONITE SEAL- 5.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one W/long is sufficient) 22.Certification:
360 24' 49.98" N 780 57' 08.80" W 140el�A7��* 09/24/21
6.Is(are)the well(s)' 29Permanent or ❑Temporary Signature of Certified Well Contractor ' Date
By signing this farm,1 hereby certify that the we/l(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
Iflhis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well oumer.
repair under rill remarks section or on the back of 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: 2S.O (ft.)
For mulliple wells list all depths ifdifferetn(example-3@200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
16.0 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 tearer level is above casing,use"+"
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 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 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018