GW1-2022-08727_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4475
ft. ft.
NC Well Contractor Certification Number yyy yg� 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION q a Bay FROM TO DIAMETER THICKNESS MATERIAL
rj�q q IRR���---888 ft. ft. in.
Company Name _
16.INNER CASING OR TUBING eorhermal closed-too
2.Well Construction Permit#: M 3 AY 0 2022 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable u•c/l construction permits(i.e.UIC,County,State,Irarionce,etc.) 0.0 ft- 5.0 ft. 2.0 in- SCH 40 PVC
3.Well Use(check well use): In{O{itiila� ' dam' URA fr. fr. in.
t-4`1 1 � 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft• 20.0 ft' 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑1rr1 ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0_0 ft. 1.0 ft- PORTLANDBENTONITE SLURRY
TMonitoring ❑Recovery fr. fr.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3.0 tt. 20.0 ft. 20-40 FINE SILICA SAND
El 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,soil/rock type,gmin size,etc.)
0.0 ft- 1.0 ft- GRAVEL/ASPHALT
4.Date Well(s)Completed: 03/25/22 Well ID# MW-1 1.0 It. 10.0 ft- RED SILTY CLAY
5a.Well Location: 10.0 ft' 20.0 ft- BROWN SILTY CLAY
PILOT - 683 ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1800 PRINCETON-KENLY ROAD KENLY 27542 ft. ft.
Physical Address,City,and Zip ft. ft.
JOHNSTON 21'.REMARKS'
County Parcel Identification No.(PIN) BENTONITE SEAL-1.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 34' 27.45" N 780 08' 44.02" w 04/04/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 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
if this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or at 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 I 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 mtdtiple wells list all depths ifdii ferent(example-3 r@r 200'and 2@100')10. Submit this GW-1 within 30 days of well completion per the following:
15.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
!fwater level As above caring,use"+"Static water level below top of casing: (ft.) Information 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(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018