GW1-2022-08841_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 TO DESCRIPTION
ft. ft.
A - 4459 ft. ft.
NC Well Contractor Certification Number I&OUTER CASING for multi=cased'wells OR LINER if a` licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft.
is
Company Name
"16.INNER CASING OR TUBING 'eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Irariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: "17.SCREEN'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) rt. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT.
❑Irrl ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
IflMonitoring ❑Recovery ft. fr.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK if a 7icable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attacb additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillma type,grain sim,etc.
0.0 ft. 5.0 ft. FILL
4.Date Well(s)Completed: 05/26/22 Nell ID# TMW-1 5.0 it, 13.0 fL CLAY/ROCK
5a.Well Location: ft. ft.
GRIFFIN CLEANERS ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. f„ )
105 DOVER STREET PINEVILLE 28134 ft. ft.
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG '21.REMARKS
County Parcel Identification No.(PIN) TEMPORARY
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 05' 07.44" N 800 53' 28.96 W 06/15/22
6.Is(are)the well(s): ❑Permanent or MTemporary 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 ONo 15A NCAC 02C.0100 or 15A'NCAC 02C.0200 Well Construction Standards and that u copy
If this is a repair,fill out known ivell construction information and explain the nature of the of this record has been provided to the well owner.
repair under 421 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'fonsTfu�rfFnfo : t
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach add ttonal pagtwif.necesslaryy--.-��•r
drilled: 24.SUBMITTAL INSTRUCTIONS P
13.0 AUG 2 C 2O22
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the followin
For multiple wells list all depths ifdiifferent(example-3@200'and 2@100D �t yr r l 1?' � GiyiY;' U nli
10.0 24a. For All Wells: Original form to Division of'Water ReV4t 2�i1i2),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
j",(1s
If water tenet is above casing,use"+"
11.Borehole diameter-' 2.25 (ill,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: DPT RODS
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:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018