GW1-2022-08625_Well Construction - GW1_20220826

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL '14.WATER ZONES''
Well Contractor Name FROM ft. ft.TO DESCRIPTION
A - 4459 ft. ft.
NC Well Contractor Certification Number 15 OUTER CASING for multi-cased"wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
in.
Company Name
46.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM: TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 5.0 ft- 2.0 in, SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
f.17.SCREEN
Water Supply Well: FROM TO DIAMETER 4SLOTSIZE THICKNESS MATERIAL'
❑Agricultural ❑Municipal/Public 5.0 ft' 10.0 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) 18.GROUT .
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 1` 3.0 ft. PORTLANDBENTONRE SLURRY
15Monitoring ❑Recovery ft. ft.
Injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL'PAC K if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft. 12.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additiorialsheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft• 5.0 ft' FILL
4.Date Well(s)Completed: 05/26/22 well ID# MW-2 5.0 ft• 12.0 ft. CLAY/ROCK
Sa.Well Location: ft. ft.
GRIFFIN CLEANERS ft. ft.
Facility/Owner Name Facility lD9(if appii:able) ft. ft.
105 DOVER STREET PINEVILLE 28134 ft. ft.
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG i21: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 ha/long is sufficient) 22.Certification:
350 05' 07.44" N 800 53' 28.96" W 06/15/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofrhe ofthis record has been provided to the well owner.
repair under 921 remarks section or on the back ofthis 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12.0 (ft.)
For multi le wells list all depths i di erent(example-3 00'and 2 100' Submit this GW-1 within 30 days of well completion•per the,folio mgl',
t. o q,..,,
DRY 24a. For All Wells: Original form to Division of a1eF-R6 urces (DWR)),
10.
.Static water level ow top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699A;(17 2 G 20ZZ
1 water level is above casing,use"+" U I
11.Borehole diameter: 8.0 (in,) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636 Ift#D�..r, C� r; •:::;j Unil
12.Well construction method: AUGER nr�t;��L`'..;
24e.For Water Supply and Open-Loop Geothermal Return�!eils'('opy 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