GW1-2022-08382_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
� rt. fr.
A - 4459 �, � ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased1wells OR LINER if a licable
GEOLOGIC EXPLORATION MAY 3 0 2022 FROM TO DIAMETER THICKNESS MATERIAL"
ft. ft. in
Company Name jrl'or ;two i UnK
� 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:
JIB Q';0;0G FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 10.0 ft. 2.0 rn' I 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 10.0 It' 20.0 ft• 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) f8.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 5.0 it. PORTLAND BENTONITE SLURRY
[EMonitoring ❑Recovery ft. ft.
Injection Well:
ft.
❑Aquifer Recharge ❑Groundwater Remediation ft.
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test ❑StormwaterDrainage 8.0 ft. 20.0 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,soiltmck type,grain size,eta
0.0 ft• 4.0 ft. SILTY CLAY
4.Date Well(s)Completed: 04/13/22 Well ID# MW-19 4.0 ft• 20.0 It. SANDY SILT
Sa.Well Location:
ft. ft.
SAAB ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
608 EAST MCNEILL STREET LILLINGTON 27546 ft. ft.
Physical Address,City,and Zip ft. ft.
HARN ETT 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-5.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35e 23' 25.32" N 780 48' 32.62" W
04/25/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCcrtified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the ivell 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 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: 20.0 (ft.)
For multiple wells list all depths ifdii ferent(example-3 200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10•0 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifivater level is above casing,use"+"
f Static water level below top of casing: (ft.) Formation 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(gP m) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018