GW1-2022-07674_Well Construction - GW1_20220818

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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
4504-A 265 ft. 285 ft. FINE SAND
360 ft- 380 ft- FINE SAND,TRACES OF LIMESTONE LAYERS
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Iieeble
A.C. Schultes of Carolina, Inc. FROM TO DIAMETER TffiCKNESS MATERIAL
0 ft- 110 ft- 20 i" .375 1 Carbon Steel
Company Name 16.INNER CASING OR-TUBING embermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft.
3.Well Use(check well use): ft• ft. in.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural OMunicipal/Public 265 ft' 1285 r" 12 in. .030 .375 1316SS
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) 3� ft' 12 i" 1.030 1.375 1316SS
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUTI "
Olrrr atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ­ -% 0 ft. 230 ft. SLURRY MIX TREMMIE
OMonitoring ❑Rec v ry e ft. ft.
Injection Well: 2022 ft. ft.
OAquifer Recharge ❑Ground r R eta ton
A9,SAND/GRAYEL,PACK_rfi plicable-
❑Aquifer Storage and Recovery ❑S .L IFS R; c; y,ng Urth FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDi'IQROG 230 ft• 385 ft- 1A TREMMIE
❑Experimental Technology []Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG-attach additionaIsheets ifnecessa '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRDPTION color,hardness,soil/rock type,grain size etc
0 ft. 10 ft• Yellow Clay
4.Date Well(s)Completed: 10/13/2021 well ID# 16 10 ft• 70 ft. Sand and Clay
5a.Well Location: 70 ft. 80 ft- Gray Clay Rock at 75 FT
Town of Wallace 88 ft' 98 ft- Sand/Clay/Shells/Hard at 92 FT
Facility/Owner Name Facility ID#(if applicable) 98 ft- 108 ft. Sand/Shell/Clay
108 Eastwood Street, Wallace 108 "' 118 ft- Sand/Shell/Rock
Physical Address,City,and zip 118 ft' 128 ft. Sand/Shells/Traces of Clay
D u pl i n 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatilong is sufficient) 22.CertifiC on:
34.74837 N 77.96272 W ,
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6.Is(are)the well(s): OPermanent or ❑Temporary SignaLi ral`(!Xli 1 C tractor Date
By signing this form,I b certify chat th ell(s)was(wereJ constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IlNo 15A NCAC 02C.010 or A 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 of the of this record has been provided to the well 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 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 ifdifferent(example-3@200'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 60 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwarerleve!is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
19 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: 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: 24 HR
422 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HYPOCHLORIDE Amount: 5 GAL
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018