GW1-2022-08273_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 _ 1. .,"-
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4459
ft. ft.
NC Well Contractor Certification Number �15 OUTER`CASING for,ulti-casbd;ills ORsLINER if�a'"� livable ,
GEOLOGIC EXPLORATION FROM To DIAMETER 7711CKNFSS MATERIAL
ft. ft. in
Company Name
16.'INNER CASING OR TUBING;'`eottiermal closed-too `'
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 5.0 fl- 2.6 1O SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: A7.SCREEN,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 IL 15.0 It' 2.0 'n- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft ;n.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18sGR70UT
❑Irrt ation ❑Wells>100000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 3.0 fL PORTLANDBENTONITE SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft, ft.
19.SAND/GRAVELIPACK ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMEPHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft- 15.0 It- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING"LOG`attachladditionAl sheets"iRnecesaa` '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soillrock tyM grain size,etc.
0.0 ft- 15.0 ft SILTY SAND
4.Date Well(s)Completed: 07/13/22 shell ID# MW-12 ft. If.
5a.Well Location: ft. ft.
UNIFIRST ft. M
Facility/Owner Name Facility 1D#(if applicable) ft. ft .;`✓'
6756 MARKET STREET WILMINGTON 28405 ft. ft. _ Ur:It
Physical Address,City,and Zip ft. ft. OaOt 2f r�043
NEW HANOVER �'21.:REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
340 15' 30.07" N 770 50' 04.92" W
e'�-�-� 07/29/22
6.Is(are)the well(s): OPermaneut or ❑Temporary Signature of Certified Well Contractor. Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If 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 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 I GW-I 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: 15.0 (ft.)
For multiple wells list all depths ifdi,/ferent(example-3@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: 6.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,161TMSC,Raleigh,NC 27699-1617
if water level is above casing,use
$•0 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Suably 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 m Method of test Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gP )
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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