GW1-2022-07831_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATERs:ZONES .
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4475
ft. ft.
i
NC Well Contractor Certification Number 15.OUTER CASING for multi=cased wells)if i liceble
GEOLOGIC EXPLORATION FROM To DIAMETER THICIINESS MATERIAL
ft. ft. in.
Company Name
IC INNER CASING OR ING eoihermal closed-loop),
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. 5.0 ft. 2.0 in- SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 tt. 20.0 tt. 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.fGR0UT°
❑lrrl ation ❑Wells>100,000 GPD, FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2.0 ft' PORTIANDSENTONRE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft tr
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAY EL'PACK+if 0 liceble..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage 3.0 ft. 20.0 ft. 20-46 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I'
❑Geothermal(Closed Loop) ❑Tracer 20:DRILI ING[OG ettaih'sdditroniil4beets,'if-neeessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soi0rock tyM grain size,etc.
0.0 ft. 1.0 ft. CONCRETE
4.Date Well(s)Completed: 06/20/22 Well ID# MW-8 1.0 ft. 10.0 ft. RED SILTY CLAY
Sa.Well Location: 10.0 ft. 20.0 "' BROWN SILTY CLAY
CIRCLE K- 2723843 ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
4470 NC - 87 SANFORD 27332 ft. ft.
Physical Address,City,and Zip ft. ft.
LEE 21.`REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-2.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tatilong is sufficient) 22.Certification.-
350 25' 26.39" N 790 07' 14.21" W � � ~
07/11/22
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
By signing this form,I hereby certify that the well a 1' ru te�l in cco}do ce with
7.Is this a repair to an existing well: ❑Yes or IJNo 15A NCAC 02C.0100 or 15A NCAC 02C 10100 WelPConstrucnon tandards and i t a copy
If this is a repair,fill out known well construction information and explain the nature of the ofihis record has been provided to the well owner. �� 2
repair under#2/remarks section or on the back ajthis form.
23.Site diagram or additional well'details: AUG 2 2
You may use the back of this page to pro . gnat-we�I&;cclns( t info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same �,
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You ma o a{(a v d+ oS Images if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20.0 (ft.) 1
Tor multiple wells list all depths ifdiJjerent(example-3Q200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
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 Sunni Sunniv and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departmenUof the county where installed
1 1.
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over`100 000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Ralet ,NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
i
it
f