GW1-2022-07671_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Irvinn Gutierrez-Bautista 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4504-A ft. ft.
NC Well Contractor Certification Number ISi OUTER CASING for multi-cased.wells OR LINER 'Ia livable
A.C. Schultes of Carolina, Inc. ' Y ! FROM To DIAMETER TalclavEss ARTERIAL
ft.
Company Name
+ 16.INNER CASING OR TUBING eo'thermal closed-loci
2.Well Construction Permit#: AIJG ! S 2022 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, VgCiance etc.) ft. ft. in.
w3313'fl Uno ft. ft. in.
3.Well Use(check well use):
Water Supply Well: 17.SCREENFROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural InMunicipal/Public 360 e' 380 ft. in.
❑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: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
OAquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVEI PACK.'if.`s'""'livable '` r w s =
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test 0 ❑Stormwater Drainage ft. ft.
❑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/rock min size,etc.
128 ft. 148 ft. Sand/Shells/Clay/Limestone
4.Date Well(s)Completed: 10/13/2021 Well ID# 16 148 ft- 158 ft- Sand/Shells/Traces of Clay
5a.Well Location: 158 ft' 178 ft- Sandy Gray Clay/Shells/Rock
Town of Wallace 178 ft- 198 ft- Limestone/Sand/Traces of Clay
Facility/Owner Name Facility ID#(ifapplicable) 198 ft- 228 ft- Clay/Limestone
108 Eastwood Street, Wallace 228 ft- 248 ft. Clay/Traces of Limestone
Physical Address,City,and Zip 248 ft' 258 ft- Gray Clay/Find Sand
Duplin 2LREMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22. rtifieation:
34.74837 N 77.96272 W r o1
6.Is(are)the well(s): IlPermanent or ❑Temporary gna e o e ed a orWactor Date
By signing this f hereby certi at the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or l5A NCAC 02C.0100 Well Construction Standards and that a copy
1f this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of ihis 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 additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 385 (ft.)
For multiple wells list all depths ifdi jerent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
60 24a. For All Wells: Original form to Division of Water Resources (DwR),
/jwater[evel is above casing,use"+"
f Static water level below top of casing: (ft.)
Processing Unit, 1617 I MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 19 (in,) 24b. For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
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) 422 Method of test: 24 H R Permit Program,1611 MSC,Raleigh,NC 27699-1611
136.Disinfection type: HYPOCHLORIDE Amount: 5 GAL
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018