GW1-2023-00786_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
CARL CARPENTER 14.WATER ZONES
Well Contractor Name FROM ft. TO DESCRIPTION
��, ?l ft. f�
A - 4475 � D ft. I.
I
NC Well Contractor Certification Number I J��I n1 15.OUTER CASING for multi-cas'ed+yells OR LINER if a licable
GEOLOGIC EXPLORATION JAN v �� FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
If15Gi i:;';;;..• 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit# v%'+ JOG FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ire/l construction permits(i.e.UIC,County,Stare,Variance,etc•.) 0.0 fL 45.0 ft• 2.0 '"' 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 45.0 ft' 50.0 ft• 2.0 1n. 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 40.0 ft' PORTLANDBENTONITE SLURRY
(DIVlonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a p licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 43.0 tt• 50.0 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,soil/rock e, nin size,etc.
rO.O
ft. 1.0 ft- ASPHALT
4.Date Well(s)Completed: 09/26/22 Well ID# MW-11 10.0 tt• RED SILTY CLAY
5a.Well Location: 30.0 ft- TAN SILTY CLAY
VILLAGE CLEANERS 50.0 ft. BROWN SILTY SAND
Facility/Owner Name Facility lD#(if applicable)
rt. ft. !
10183 US HIGHWAY 70 CLAYTON 27520 ft. ft.
Physical Address,City,and Zip ft. ft.
JOHNSTON 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-40.0-43.0 FEET
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35° 35' 31.75" N 78° 24' 07.16" W 10/03/22
6.Is(are)the well(s)• OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify ilia[the well(s)was(here)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 cow
If this is a repair,fill out known well construction h Jbrnnation and explain the nature of rile ofdtis•record has been provided to the well owner.
repair under#21 remarks section or on the back of this•fora.
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: 50.0 (ft*)
For ouhiple wells list al/depths tfdierent(example-3« 00'and 2 r@100) Submit this GW-1 within 30 days of well completion per the following:
13.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water Ierel is above casing,use"+"
11.Borehole diameter: 8•0 (in.) 24b. For Injection Wells:Copy to!DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 276994636
12.Well construction method: AUGER i
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departm I ent 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: i
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018