GW1-2022-06442_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 'A4.WATER ZONES•.
Well Contractor Name FROM TO DESCRIPTION
ft. ft
A - 4475
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. h
Company Name
16.INNER CASING.OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 10.0 ft. 2.0 1O' SCH 40 PVC
3.Well Use(check well use): ft. It. in.
17.'SCREEN_ ,. xi, , , ,"> ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0"' 20.0 It' 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
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERL►L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 6.0 It. PORTLAND BENTONITE SLURRY
IflMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
SAND/GRAVEL PACK ifa licrible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERL►L EMPLACEMENT METHOD
El Aquifer Test ❑StormwaterDrainage 8.0 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(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type rain size,etc
0.0 ft. 1.0 ft. TOPSOIL
4.Date Well(s)Completed: 04/05/22 Well ID# MW-8 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) BENTONITE SEAL-6.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certification'
360 03' 55.05" N 790 18' 35.73" �n��'� s 04/25/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert(y that the well(s)ivas(were)constructed in accordance ivith
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
Ifthis is a repair,fill out known ivell construction information and explain the nature ofthe ofthis record has beenprovided to the Nell 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 ad tI I well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attaN itional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS ha
2 7 LULL
9.Total well depth below land surface: 20'0 (ft.) Submit this GW-1 within 30 days of well om�pletion per the following:
For multiple wells list all depths rfdierent(example-3 200'and 2@I00) y p p g'
10.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
ifivaler level is above casing,use"+"
f Static water level below top of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
$.0 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018