GW1-2022-06441_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES,,
Well Contractor Name FROM TO DESCRIPTION
ft. ft i
A - 4475 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for mulii-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO MATER DIAMETER THICKNESS IAL
ft. ft. is
Company Name
16.INNER CASING OR TUBING cothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) 0.0 ft. 10.0 ft. 2.0 'n' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: �47.SCREEN
FROM TO DIAMETER G SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft 20.0 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
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 6.0 ft' PORTLAND BENTONrrE SLURRY
29Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 8.0 ft. 20.0 ft- 20-40 FINESILICASAND
❑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(ock typc rain size,etc
0.0 ft. 1.0 ft. TOPSOIL
4.Date Well(s)Completed: 04/05/22 Well ID# MW-7 1.0 ft. 10.0 ft RED SILTY CLAY
5a.Well Location: 10.0 ft' 20.0 ft' BROWN SILTY CLAY
PILOT- 57 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
1342 TROLLINGWOOD HAWFIELDS ROAD MEBANE 27302 ft. ft.
Physical Address,City,and Zip ft. ft.
ALAMANCE 21 REMARKS -
County Parcel Identification No.(PIN) BENTONIfE SEAL-6.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
360 03' 55.92" N 790 18' 33.31" W 04/25/22
6.Is(are)the well(s): [EPer'manent or ❑Temporary Signature of Certified Well Contractor Date'
By signing this form,I hereby certify that the ivell(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ITNo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known ivell construction information and explain the nature of the ofthis record has been provided to the ivell 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 additiona ll construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach add pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20.0 (ft.) ��r'�
For multiple wells list all depths ifili ferem(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: 10.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifivater level is above casing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018