GW1-2023-00876_Well Construction - GW1_20230118

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES
gyp''^' FROM TO DESCRIPTION
Well Contractor Name .
' ft ft.
A - 4475
L.
,e s � rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable)
GEOLOGIC EXPLORATION JAN $ S 2023 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name lfgofma�iM1 i7f.:'✓'�+�`•� 16.INNER CASING OR TUBING eother at closed-loop)
2.Well Construction Permit#• clWaiuO' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.UIC,County,Stale,Variance,etc.) 0.0 ft- 30.0 ft. 2.0 '"' SCH 40 PVC
3.Well Use(check well use): ft. ft. "•
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30.0 ft' 45.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(1-Ieating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 25.0 ft' PORTLANDBENTONLTE SLURRY
[EMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonmwater Drainage 28.0 ft• 45.0 fL 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. rt.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Iieating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 1.0 ft' GRAVEL
4.Date Well(s)Completed: 10/10/22 Well ID# MW-1 1.0 ft. 10.0 ft. RED CLAY
ia.Well Location:
10.0 ft' 20.0 f" RED SILTY CLAY
CAMP LURECREST 20.0 ft. 30.0 ft. TAN SILTY CLAY
Facility/Owner Name Facility ID#(ifapplicable) 30.0 ft. 45.0 ft- BROWN SILTY SAND
207 LURECREST DRIVE LAKE LURE 28746 ft. ft.
Physical Address,City,and Zip ft. ft.
RUTH ERFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-25.0-28.0 FEET
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification:
350 25' 17.22" N 820 11' 25.23" W G� = 10/31/22
6.Is(are)the well(s): MPermanent 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 Cotrsiruction Slandards and thal a copy
1f this•is a repair,fill out known well construction informalion and explain the nature of the of this record has been provided to the well owner.
repair under P21 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 well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wel Is (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: 45.0
For multiple wells list all depths ifdijJerent(example-3 rr 00'and 2@100') Submit this GW-I within 30 days of well completion per the following:
35.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above caring,use"+"
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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13:t.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018