WM0100509_Monitoring Well Construction Records_20220429

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 1A WATER ZONES','-
Well Contractor Name
FROM TO DESCRIPTION
ft. ft.
A - 4459
ft. ft.
NC Well Contractor Certification Number e,45.'0UTER CASING(for°multi-cased wells ORLTdNER`ifa Iicable;
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. is
Company Name
t`x,1&INNER-ASING OR TUBING; eotheroW ilowdl _oo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS .
x
MATERIAL
List all applicable well construction permits#.e.UIC,County,State,Variance,etc.) 0.0 ft- 12.0 ft- 2.0 1° SCH 40 PVC
3.Well Use(check well use):
ft. ft. in,
Water.Supply Well: 17i:SCREENr -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 12.0 ft' 32.0 It' 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 ft- 7.0 ft' PORTLAND BENTONITE SLURRY
EMonitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
719 SAND/GRAVEL PACK ifa fieable c
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENTMET IOD
Aquifer Test StormwaterDrainage 10.0 It- 32.0 ft- 20-40 FINE SILICA SAND
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:"DRILLING.IOG.attachadditi6n4lsheetsifueces"sa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
FROM TO DESCRIPTION color,hardness,soilfrock type,grain size,etc.
0.0 ft- 0.5 ft- ASPHALT
4.Date Well(s)Completed: 04/20/22
Well ID# MW-23 R 0•5 ft. 1.0 ft. ROCK
5a.Well Location: 1.0 ft' 5.0 ft' CLAY BACKFILL
HUDSON SUPERETTE 5.0 ft- 32.0 ft- RED CLAY
Facility/Owner Name Facility ID#(if applicable) 'rt. ft. j
583 MAIN STREET HUDSON 28638 ft. ft.
Physical Address,City,and Zip ft. ft.
CALDWELL k 21-REMARKS:: . .
County Parcel Identification No.(PIN)
BENTONITE SEAL-7.0-10.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if well field,one lat/long is sufficient) 22.Certification:
350 50' 44.77" N 810 29' 32.88" W 04/29/22
6.Is(are)the well(s): INPermanent or Temporary
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)tvas(were)constructed in accordance with
7.Is this a repair to an existing well: Yes or 119No ISA 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 ofthe ofthis record has been provided to the well owner.
repair under#21 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 Over'in Remarks Box).You may also attach ad it pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
32.0 ft) L M??
For multiple wells list all depths ifdierent(example-3@200'and 2@100)Submit this GW-I within 30 days of well complEtion pethe following:
10.Static water level below top of casing:
22.0 ft.)
24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use••+•
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 thei.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
i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL i4.'.wATER.ZONES
Well Contractor Name
FROM TO DESCRIPTION
ft. ft.
A -4459
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for'multi=cased swells`OR LINER'ifa``6cable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING 'eothermal closed-loon)'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 12.0 ft. 2.0 In- SCH 40 PVC
3.Well Use(check well use):
ft. ft. in.
Water Supply Well: 17.SCREEN E 's
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 12.0 It. 32.0 It. 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
Irrl ation Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It. 7.0 ft' PORTLANDBENTONRE SLURRY
0flMonitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable -'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test StormwaterDrainage 10.0 ft. 32.0 ft. 20-40 FINE SILICA SAND
Experimental Technology El Subsidence Control it.
Geothermal(Closed Loop) Tracer 20."DRILLING'LOG attach additional sheets if necessary)
Geothermal(Heating(Cooling Return) Other(explain under#21 Remarks)
FROM I TO DESCRIPTION color,hardness,soittrock type,grain size,etc.
0.0 it. 0.5 f. ASPHALT
4.Date Well(s)Completed: 04/20/22
Well ID# MW-6R 0.5 ft. 1.0 ft. ROCK
5a.Well Location: 1.0 ft. 5.0 ft' CLAY BACKFILL
HUDSON SUPERETTE 5.0 ft- 32.0 ft. RED CLAY
Facility/Owner Name Facility ID#(if applicable) ft. ft.
583 MAIN STREET HUDSON 28638 ft. ft.
Physical Address,City,and Zip ft. ft.
CALDW E LL 21.REMARKS`,=°
County Parcel Identification No.(PIN) BENTONIfE SEAL-7.0-10.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if well field,one lat/long is sufficient) 22.Certification:
35e 50' 43.38" N 810 29' 34.67"
W e'e 04/29/22
6.Is(are)the well(s): 29Permanent or Temporary Signature ofCertified Well Contractor Date
By signing this farm,I hereby certify that the wells)ivas(were)constructed in accordance ivith
7.Is this a repair to an existing well: Yes or ONo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f 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 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'D nstruction 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: MAY 2 7 20E1224.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
32.0 ft.)
For multiple wells list all depths ifdierent(example-3@200'and 2@100)Submit this GW-1 within 30 days of well completion per the following:
22.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
fivater level is above casing,use"+"f
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(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to thei.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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018