GW1-2022-08359_Well Construction - GW1_20220411

I?�rint For-i'1 :_
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Tarrell Benford Graham Jr. .14"WATER ZONES7.,
Well Contractor Nerve FROM TO DESCRIPTION
NCWC 2373-A 72 ft. 93 Orange solid
ft. ft.
NC Well Contractor Certification Number
is76/TER•CAtSING•for inuld-cased wells UTL TNER:.ifih liable
Graham Currie Diversified Drilling LLC FROM TO DIAMETER 'THICKNESS MATERIAL
Company Nerve '
0 ft. 72 ft. 4 I in. SCh 40 1PVC
`•Ib,INNER•CASINGORc BUBING 'eothermalc1osed=too
2.Well Construction Permit#:. FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction pernilts(Le.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM
SCREEN
FROM TO DIAMETER SLOT SIZE" THICKNESS MATERIAL
Agricultural DMunicipal/Public 72 ft. 87 ft. 4 1°• 30 sch 40 PVC
:]Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) S7 ft. 93 ft' 4 in. 30 sch 40 Stainless
:.]Industrial/Commercial [3Residential Water Supply(shared) 18iGROUT,-
Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 23 ft- 72 ft. #3 sand Poured
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND`/GRAYEL> ACK if a"'liceble - _';
Aquifer Storage and Recovery 33 Salinity Barrier FROM TO MATERIAL EMPLACEMENT 1.METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20rDRILLINGdt70G=atteeli"addld6nalsheets if=necesse'
FROM TO DESCRIPTION color hardness WI/rock p e min size,etc.
Geothermal(Heating/Cooling Return Other(explain under#21 Remarks) 0 rL 15 ft• orange sand
4.Date Well(s)Completed: 1/25/2022 Well ID# 15 it. 35 ft. orange/grey sand/clay
5a.Well Location: 35 ft. 42 ft. orange sand+water
Jacob Lockhart 42 ft- 49 ft. grey,,hard clay
Facility/Owner Name cility ID#(ifapplicable) 49 ft. 93 ft' Orange sand +water
Fa
160 Williams Road, Pinehurst NC, 28374 93 ft' 97 ft. Grey Clay
Physical Address,City,and Zip ft, ft.
Moore 00035439 21:"REDIARKS; .
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one[atilong is sufficient) Cer Mention:
35 11' 53" N 79 25' 46" W
6.Is(are)the well(s) Permonent or OTemporary signs ofC 'red W mr Date
nmg I s orm,1 certify!that the wells)4as(were)constructed in accordance
7.Is this a repair to an existing well: Dl Yes or Callo with- C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,Jill out known well construction information and explain the nature of the copy ofthis 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(laving the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 97 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
for undliple ivells list all depths lfdii ferent(example-3(Q200'and 2@100') construction to the following:
10.Static water level below top of casing:47 (ft,) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing,use"+" 1617 Mail Service;Center,Raleigh,NC 27699-1617
11.Borehole diameter:7 I
5 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 248
Mud and Rota above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,diiect push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SuaDly&Inie tion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Dupartment of Environmental Qunlity-Division of Water Resources Revised 2-22-2016