GW1-2022-06533_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL `1A WATER ZONES','­
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4459 ft. ft.
NC Well Contractor Certification Number e,45.'0UTER CASING(for°multi-cased wells ORLTdNER`ifa Iicable;
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. is
Company Name t`x,1&INNER-ASING OR TUBING; eotheroW ilowdl _
oo °
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS .x MATERIAL
List all applicable well construction permits#.e.UIC,County,State,Variance,etc.) 0.0 ft- 12.0 ft- 2.0 1° SCH 40 PVC
3.Well Use(check well use): ft. ft. in,
Water.Supply Well: 17i:SCREENr -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 12.0 ft' 32.0 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
❑Irri ation ❑Wells>100,000 GPD FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 7.0 ft' PORTLAND BENTONITE SLURRY
[EMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
719 SAND/GRAVEL PACK ifa fieable c
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMET IOD
❑Aquifer Test ❑StormwaterDrainage 10.0 It- 32.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer �20:"DRILLING.IOG.attachadditi6n4lsheetsifueces"sa
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfrock type,grain size,etc.
0.0 ft- 0.5 ft- ASPHALT
4.Date Well(s)Completed: 04/20/22 Well ID# MW-23 R 0•5 ft. 1.0 ft. ROCK
5a.Well Location: 1.0 ft' 5.0 ft' CLAY BACKFILL
HUDSON SUPERETTE 5.0 ft- 32.0 ft- RED CLAY
Facility/Owner Name Facility ID#(if applicable) '
rt. ft. j
583 MAIN STREET HUDSON 28638 ft. ft.
Physical Address,City,and Zip ft. ft.
CALDWELL k�21-REMARKS:: . . -
County Parcel Identification No.(PIN) BENTONITE SEAL-7.0-10.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 50' 44.77" N 810 29' 32.88" W
04/29/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)tvas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 119No 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 ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 ad it pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 32.0 (ft) L� M??
For multiple wells list all depths ifdierent(example-3@200'and 2@100) Submit this GW-I within 30 days of well complEtion pethe following:
10.Static water level below top of casing: 22.0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water 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