GW1-2022-07643_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 4121
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells Olt'
if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. I ft. I in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State.Variance,etc.) 0.0 ft. 20.0 rt• 2.0 '"' I SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply PPY Well: FROM TO DIAMETER, SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 ft' 30.0 r`' 2.0 1O' .010 SCH 40 PVC
❑Geothenmal(Heat ing/Cool i ng Supply) ❑Residential Water Supply(single) ft. ft. in.'
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 12.0 ft- PORTLANDBENTONITE SLURRY
CEMonitoring ❑Recovery R. D.
Injection Well: R. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(ifopplic able
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stotmwater Drainage 17.0 rt 30.0 r`' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/mck e, min size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0.0 rr 1.0 r`' CONCRETE/GRAVEL
4.Date WclI(s)Completed: 06/21/22 Well ID# MW-4 1.0 ft 23.0 r` PWR
Sa.Well Location:
23.0 �`' 30.0 ROCK
ALVARADO HOLDINGS rr. fr.
Facility/Owner Name Facility IDH(ifa.pplicable)
1334 EAST 11TH STREET SILER CITY 27344
Physical Address,City,and Zip
CHATHAM 2L REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 12.0-17.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-
350 43' S2.93" N 790 26' 46.41" W A//� 07/11/22
of Certified Well Contractor
6.Is(are)the well(s): (9Permanent or ❑Temporary Signature ° 6
By signing this form,1 hereby certify that hi^�v 1AWT �f'-y ' accordance with
7.is this a repair to an existing well: ❑Yes or INNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
if this is a repair,fill out known feel/construction information and explain the nature of'ihe of This record has been provided to the ire//In r -s F 2
repair under,,21 remarks section or on the back ofthis forme 1 ���0 I f
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 pig eg' A 001ty3 at"ReJI W+i Utruction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).hou may a�gta� itional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30.0 (ft.)
For multiple wells li.v a//depths ifderent(example-3 tt 200'and 2 n l00') Submit this CW-1 within 30 days of well completion per the following:
25.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
/£baler level is above casing,use"
11.Borehole diameter: 6.0 (in.) 24b. For Infection Wells: Copy[,to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Ii
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018