GW1-2022-07834_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: t
CARL CARPENTER t4.:WATER10NEs"
FROM TO I DESCRIPTION
Well Contractor Name ft. ft k
A - 4475 ft. ft.
NC Well Contractor Certification Number 15:OUTER CASING for"m lh=case4;,Wil s ORL�MR ifa"°licatile
GEOLOGIC EXPLORATION FROM To DIAMETER. THICHNESS MATERIAL
ft. ft. in.
Company Name -
&INNER`CASING,ORTUBINC" eothermal.closed-loo'
2.Well Construction Permit#: Ex THICKNESS MATERIAL
FROM TO DIAMETER
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft' 5.0 ft. 2.0 1°' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17:SCREENi, °
Water Supply Well: FROM TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 5.0 fL 20.0 f" 2.0 1°' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 2,0 ft- PORTIANDBENTONnE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19r SAND/GRAVEL PACK if a` ticati`l'e
❑Aqutfer Storage d Recovery ❑Salinrt)Barrier FROM To MATERIAL MPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 3.0 ft- 20.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control tt. ft.
❑Geothermal(Closed Loop) ❑Tracer '20.DRILLING LOG;attachadditioilalaheeiv'1t neeessax
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain sae etc.
0.0 ft' 1.0 ft. CONCRETE
4.Date Well(s)Completed: 06/21/22 Well ID# MW-5 1 0 tt• 100 ft. RED SILTY CLAY
5a.Well Location: 10.0 ft' 20.0 It- BROWN SILTY CLAY
CIRCLE K - 2723843 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4470 NC - 87 SANFORD 27332 ft. ft.
ft. ft
Physical Address,City,and Zip
LEE
211tEMARKS;i
County Parcel Identification No.(PIN) BENTONITE SEAL-2.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
35e 25' 28.13" N 790 07' 15.30" W �n� 07/11/22
Signature of Certified Well Contractor --pate4.
6.Is(are)the well(s): 09Permanent or ❑Temporary s�.i , 119,
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.0200 Well Co+� 1iop'S1gpda2t f that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well•owner. I l.. 1 Z v [1��1[[�I
repair under 021 remarks section or on the back of this form.
23.Site diagram or additional welldetail$$_:= a���,�MC (f�
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to pro�iH�la"di 1pq ifhlrmtruc ion info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach d�dillon pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20'0 (ft*)
For multiple wells list all depths ifdiserent(example-3@200'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
Ifwater level is above caving,use
24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 8'0 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and O enen-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where Return
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingfover 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: f
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018