GW1-2022-07837_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL ?a4.�WATERzONEsx
Well Contractor Name FROM TO DESCRIPTION
A - 4459 ft. ft
ft. ft. f
NC Well Contractor Certification Number &OUTER CASING'for mWti-,cased.w'etls'OR"LINER'if'a"7iciitile
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
tt. tc 1 to
Company Name
,16.,INNER CASING OWTUBING `eothermal closed-loo' .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) 0.0 ft. 10.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: =1Z'SOREEN, , - ux
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 10.0 ft. 20.0 It. 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT. .
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 5.0 It" PORTLANDBENTONITE SLURRY
I5Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
�19.'SAND/GRAVEL-PAC K ifalieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMEI'HOD
❑Aquifer Test ❑Stormwater Drainage 8.0 ft- 20.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ;307DRIL III,iNG1OG Nttaebadditional she 6 ifhkesia
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 ReML)i
FROM TO DESCRIPTION color,hardness,soiltrack tyM grain sim etc.
0.0 ft- 20.0 ft- SANDY CLAY
4.Date Well(s)Completed: 07/14/22 Well ID# MW-5 ft. ft.
Sa.Well Location:
ft. ft.
BARRETTS CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) fl. ft. I
261 NC - 42 CLAYTON 27886 ft. ft.
Physical Address,City,and Zip ft. ft.
JOHNSTON 1:xEMARxs:��
County Parcel Identification No.(PIN) BENTONITE SEAL-5.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35° 38' 20.72" N 780 26' 26.19" W 07/21/22
6.Is(are)the well(s)• EPermanent or ❑Temporary Signature of Certified Well Contractor :�eftep, y
By signing this form,I hereby certify that the well(s)wds(wdreftans'Ti firtedtn accdr;d ee with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
Ifilds is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner. P (� ) 202�
repair under#2/remarks section or on the back ofthis farm.
23.Site diagram or additional well details: �Ir�
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to proviljvWddt SaF1v e11QS1�r10
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach adWdQ if necessary.
drilled: 24.SUQMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20'0 ft.
For multiple wells list al/depths tjdi,(ferem(example-3 r@200'and 1«100') ( ) Submit this GW-1 within 30 days,of well completion per the following:
10.Static water level below top of casing: 12.0 (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)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loon 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: E
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources: Revised 6-6-2018
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