GW1-2022-07839_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4459 ft. ft.
NC Well Contractor Certification Number 15 OUTER CASING for multi-cesetd:wills OR'LINER ifa "licable .i
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eoth6mal closed-loon
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,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 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 ft' 30.0 It' 2.0 in' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndustriaVCommercial ❑Residential Water Supply shared
PP Y(shared) 18.GROUT �..
❑Irrl ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0_0 ft. 20.0 n' PORTLANDBENTONRE SLURRY
IBMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK`if applieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 23.0 ft• 30.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG amch'idditimial shiits ifnicessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrork tyM grain sizA etc.
0.0 1" 30.0 ft- SILTY SANDY CLAY
4.Date Well(s)Completed: 05/23/22 well ID# AS-1 ft. ft.
Sa.Well Location:
ft. ft.
PEGGYS QUICK MART ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. I
5403 FLOWER HILL ROAD KENLY 27542 ft. ft.
Physical Address,City,and Zip ft. ft.
JOHNSTON 21REMARKS '�-
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:
35e 40' 41.90" N 780 10' 10.73" W
06/15/22
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature of Certified well Contractor Date
By signing this form,/hereby certify that the well(s)was ve,'e c�ns0cteedThWlpoA
7.Is this a repair to an existing well: ❑Yes or 19No 15A NCAC 01C.0100 or 15A NCAC 02G.0200 Well Cc�rsr�uF o�t<2S�ardssar irlr t a o
1f 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. /-�.iL rf
23.Site diagram or additional well details: �.I r .�i .�i Z1,,n 2/_
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�d¢tig4�ppggp�s +
drilled: 24.SUBMITTAL INSTRUCTIONS 31,AQ/3013
9.Total well depth below land surface: 30.0 (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: DRY (ft) 24.9. For All Wells: Original form to Division of Water Resources (DWR),
!J',varer 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-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(gpm) Method of test Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018