GW1-2022-03360_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4121
ft. ft. �
NC Well Contractor Certification Number t
15.OUTER CASING for multi-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-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 15.0 ft- 2.0 '"' 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 15.0 ft• 30.0 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
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 10.0 ft- PORTLANDaENTONITE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well:
ft. 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- 30.0 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/rock type,gimin size,etc.
0.0 ft 21.0 ft• BROWN SILTY CLAY
4.Date Well(s)Completed: 09/02/21 Well ID# MW-g 21.0 ft 30.0 ft- BROWN SILT
5a.Well Location: ft. ft.
RAYS CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1526 NORTH BRIDGE STREET ELKIN 28621 ft. ft.
Physical Address,City,and Zip ft. ft.
SU RRY 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 10.0-13.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
360 16' 18.74" N 800 51' 11.06" W 09/24/21
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this Jbrm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or INNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f 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 021 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: 30.0 (ft.)
For multiple wells•list all depths ifdifjerent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
21.0 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
/f water 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
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018