GW1-2022-07806_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL
714-_WATER ZONES= � 1 .•
Well Contractor Name FROM TO DESCRIPTION
A - 4459 ft. e.
ft. ft I,
NC Well Contractor Certification Number
15rDUTER:CASING for-multi=cased wells,OR LINER`if i"liceble`r
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name
ft. fL in,
7b.^INNER CASING'OR<--TUBING ieothermal`tlosedloo'"" '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.) 0.0 ft- 25.0 ft- 2.0 in- SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: '17.SCREEN `
FROM TO DIAMETER, SLOTS[ZE THICIaVESS
❑Agricultural ❑Municipal/Public fL m
2.0 .010 SCH 40 PVC MATERIAL
25.0 35.0 ft.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft. ft. m.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18L`43ROUT,•,+ � -
❑bTl ation ❑Wells>100.000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 20.0 ft' PORTLANDaENTONRE SLURRY
09Monitoring ❑Recovery ft. ft.
Injection Well:
U. ft.❑A uifer Recharge ❑Groundwater Re mediation
❑Aquifer Storage and Recovery ❑Salmi Barrier 19 SAND/GRAVEL PACK if a' licible
ry FROM TOI MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 23.0 ft- 35.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer •20.DRILLING'LOG attach additioniilYsheets itvecesaa �xs�.> .
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIFTIO eoKar,hardness soiuroek rain sue etc.
0.0 IL 35.0 fL SILTY CLAY
4.Date Well(s)Completed: 07/19/22 Well ID# MW-6 ft. ft.
5a.Well Location: ft. ft. a w,
REGINA LEWIS PROPERTY ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. #:*
AUG I
11608 NC - 62 BURLINGTON 27217 ft.
Physical Address,City,and Zip ft. M*atl.Il80G
GUILFORD 321:REMARKS° .°a
County Parcel Identification No.(PIN) BENTONITE SEAL-20.0-23.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-.
360 15' 52.61" N 790 20' 28.35" W
4�2�' 07/29/22
6.Is(are)the well(s): 29Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or 15A NCAC 02C.0100 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 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 G W-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: 35.0 '
(fh) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ijd fferent(example-3 a( 00'and 1Qa 100�
10.Static water level below top of casing: 32.0 (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)
AUGER Program,1636 MSC,Raleigh,NC 2699-1636
i..Well construction method: 24c.For Water Supply and Onen-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(gP m) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Forth GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018