GW1-2022-08263_Well Construction - GW1_20220530

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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 r+� FROM ft. TO ft DESCRIPTION
A - 4459 `� �.,� IV D
ft. fr. �
q
NC Well Contractor Certification Number MAY 3 0 2022 15.OUTEWCASING'for ruulMased=wells OR LINER(if a'licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name lflia7".I%1 'f 0':w.,..;
Et
ft. na
x� '16.INNER CASING OR TUBING' eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 13.5 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 ❑MunicipaVPublic 13.5 It' 23.5 11- 2.0 "' 1 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT=
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 9.5 ft. PORTLANDBENTONITE SLURRY
[EMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
`.19.SAND/GRAVEL PAC K(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 11.5 ft. 23.5 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size.etc.
0.0 ft. 23.5 ft. TAN SAND
4.Date Well(s)Completed: 02/22/22 well ID# MW-16 ft. ft.
5a.Well Location: ft. ft.
MCOLF OAK GROVE ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1380 OAK GROVE ROAD TRENTON 28585 ft. ft.
Physical Address,City,and Zip ft. ft.
.J O N ES 21.REMARKS.
County Parcel Identification No.(PIN) BENTONITE SEAL-9.5-11.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 02' 01.22" N . 770 15' 18.47" W �� �
03/09/22
6.Is(ire)the well(s): TPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert fy that the ivell(s)ivas(ivere)constructed in accordance tivilh
7.Is this a repair to an existing well: ❑Yes or IENo 15A NCAC 02C.0100 or 15A NCAC 02C.0200(Yell Construction Standards and that a copy
If this is a repair,fill out known ivell construction information and explain the nature of llte ofthis record has been provided to the ivell owner.
repair under#21 remarks section or on rite back of this 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 GW-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: 23.5 (ft')
For multiple wells list all depths ifdierent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
15.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+"
f Static water level below top of casing: (ft.) 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 GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018