GW1-2022-03313_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION.
A - 4475 rt. a.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.IIIC,County,State,Variance,etc) 0.0 ft. 15.0 ft. 2.0 i"' SCH 40 PVC
3.Well Use(check well use): ft. ft. i�•
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15.0 ft' 20.0 ft. 2.0 "' 1 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft, in.
❑Industrial/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 PORTLAND BENT ONITE SLURRY
❑Monitoring ❑Recovery H. ft.
Injection Well: R. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 13.0 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(Heat ing/Cool ing Return) InOther(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft• 2.0 ft. GRAVEL
4.Date Well(s)Completed: 12/21/21 Well ID# AS-2 2.0 ft- 10.0 ft. TAN SILTY SAND
5a.Well Location: 10.0 ft' 20.0 ft' GRAY SAND
FOOD MART k. a. i- .
Facility/Owner Name Facility lD#(if applicable) ft. ft.
801 NORTH MAIN STREET SALEMBURG 28385 ft. ft. MAR
Physical Address,City,and Zip ft. ft `
SAMPSON 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-.10.0'-13.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***AIR SPARGE***
(if well field,one lat/long is sufficient) 22.Certification:
35° 01' 18.18" 780 30' 08.52" / �- 12/29/21
ti G,-: .. ..
6.Is(are)the well(s)• IFPermanent or ❑Temporary Signature of Certified Well Contractor I Date
By signing this form,1 hereby certify that the well(s)was(here)construcved in accordance arid
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
//this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 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 I 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: 20.0 (ft.)
hur multiple webs list all depths ifdi erem(example-3@200'and 2 ct 100') Submit this GW-1 within 30 days of well completion per the following:
10.0 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"+" i
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-Loon 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
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources) Revised 6-6-20I8