GW1-2022-05322_Well Construction - GW1_20220527

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 fr. tr
NC Well Contractor Certification Number 15:'OUTER CASING"foi multi-cased webs`OR LINER ifia 7icable "
GEOLOGIC EXPLORATION FROM TO DIAMETER TRICKINESS MATERIAL "
Company Name
0.0 It. 70.0 ft- 6.0 SCH 40 PVC
16.INNER-CASING.OR TUBING ieatliermal closed=166
2.Well Construction Permit#: 13669 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 11
FROM EE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) '18,GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
El Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVELPACK(if a 'licnhle 1 "
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. fr.
❑Geothermal(Closed Loop) ❑Tracer :20.DRILLING LOG attach'additional sheets if nec'es$a
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc
0.0 1" 4.0 ft- RED CLAY
4.Date Well(s)Completed: 04/26/22 Wel1ID# WSW-1 4.0 ft• 20.0 ft• BROWN SILTY PWR
5a.Well Location: 20.0 It' 33.0 ft' WEATHERED ROCK
AIREY RESIDENCE 33.0 ft. 495.0 It- ROCK
Facility/Owner Name Facility ID ft. ft.
#(if applicable) j
104 JULIUS MAC ROAD STANLEY 28164 ft. ft.
Physical Address,City,and Zip
ft. ft.
GASTON 21.REMARKS ,`ii
County Parcel Identification No.(PIN) OPEN HOLE-70.0-520.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 23' 21.42" N 81° 00' 31.36" W '" i 05/19/22
6.Is(are)the well(s): (EPermanent 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 ONo ISA 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 ofthis 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 wetruction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach addition. pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS !v@F 1�l 2 7 Z
9.Total well depth below land surface: 520.0 (ft.) �@
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 23.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If ivater level is above casing,use"+„ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 12.0/6.0/7.875 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/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 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 27699-1 61 1
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018