GW1-2022-08371_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
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DAVID HALL14:wATER ZONEs­-
FROM TO DESCRIPTION
Well Contractor Name A - 4459 ft ft.
ft. ft.
NC Well Contractor Certification Number
,A&OUTER'CASING�for multi-cased wets"OR=LINER'if�i licable
GEOLOGIC EXPLORATION FROM To DIAMETER TIIICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING:OR`TUBING eothermil closed loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 27.0 ft. 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM f0 DIAMETER SLOT SIZE 711ICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 27.0 ft. 37.0 ft' 2.0 in; .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. ins
❑Industrial/Commercial ❑Residential Water Supply(shared) ;18;-GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM 'r0 MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 22.0 ft- PORTLAND13ENTONITE SLURRY
[IlMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
d19:SAND/GRAVEL PACK(ifavoliei6le .
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 tt. 37.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 26.DRILLING LOG attach addttionil"sheiti if ieeessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardn soil/rock tyM zrain she,etc.)
0.0 ft• 2.0 ft. ASPHALT/GRAVEL
4.Date Well(s)Completed: 06/10/22 Well ID# MW-4 2.0 ft- 10.0 ft- BROWN SILTY SAND
5a.Well Location: 10.0 ft' 25.0 ft' TAN SILTY CLAY
SPEEDWAY - 7900 25.0 ft 36.0 ft- BROWN SAND
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. k
1206 NORTH SANDHILLS BLVD ABERDEEN 28315 ft. ft. r
Physical Address,City,and Zip ft. ft.
MOORE '21`REMARKS.,:." -
County Parcel Identification No.(PIN) BENTONITE SEAL-22.0-25.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 08' 56.91" N 790 25' 07.53" W
06/17/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the w Na3(Ivvoirs9ruc(cin a a nce with
7.Is this a repair to an existing well: ❑Yes or ONo !SA NCAC 02C.0l00 or l5A NCAC 01C.02eAToi{strxrolttrjil2lak rat a copy
If this•is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back of this form. c� n 20�?
23.Site diagram or additional well details: p,l� L h
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).Your alsq h addttibiiolik4Ds cessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 37.0 (ft.)
For multiple wells list all depths iftli ferenr(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 29•0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use + Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 246.For In Wells:Copy twDWR,Underground Injection Control(RUC)
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 61 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018