_Well Construction - GW1_20230320 (65)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Thomas.Williams 14.WATER ZONES
Well Contractor Name .. - FROM .TO DESCRIPTION '
ft. _ .. ft _
431.9=A _ ft. fL _
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if al!
licable
SW E FROM TO' DIAMETER THICKNESS MATERIAL '
ft. inv _ _
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIMIETER -THICKNESS MATERIAL .
List all applicable well construction pernn(s(i.e.UIC:County,State,Variance,etc.) 0 ft. 10.3 . ft- 2 in. SCh..40' PVC
3.Well Use(check.well use):
ft.* ft ., in.
Water Supply Well: 17.SCREEN
FROM TO DL"IETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.3 ff 20.3 .ft-. .2 '"• 0:020:in: sch.40 PVC'
❑Geothermal.(Heating/Cooling Supply) OResidential Water Supply(single) tt tt.
10.3' in.
❑IndustiiaUCommercial ❑Residential Water Supply(shared). 18.GROUT
bIrri'ation ❑Wells>100,060 GPD FROM I TO MATERIAL EMPLACEMENT 6IETHOD&ANIOUNT
Non-Water Supply Well: O ft. 5.7 . ft see remarks tremit?
[!]Monitoring ❑Recovery 5.7 ft 8 ft bentonite seal pour
Injection.Well:. .
7. ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier : FROM I TO MATERIAL - I EMPLACEMENT METHOD.
❑Aquifer Test. [7StormwaterDrainage 8 ft' 20.3 ft #2fltersand pour
❑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 421 Remarks) FROM TO DESCRIPTION color,hardness,soiUroek type,grain sire;etc.
0. ft 20.3. ft Earthen Back Fill for Dam
4.Date Well(s)Completed: 2��3�2023 .Well ID# Sta. 37+5Q, 10L ft- ft.
Sa:Well Location: ft ft f
Slate of NO Carorna-ON BEN LFOFN7LDLIFE RESOURCES COMM ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft l L'
Dunn.Road Dunn 28334 ft ft
Physical Address,City,and Zip. ft. ft
Harnett.Cou,nty _ 1504-31-3233 21.REMARKS
County Parcel Identification No.(PIN) Grout cement/bentonite mixture used
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:.
(ifwell field;one laIt/long is sufficient)• 22.Certification:
35.2259118 N -078.6521299; ,Y 3/13/2023
6.Is(are)the well(s): OPermanent or. ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that.the well(s)e•as(were)constructed in accordance,with
7.Is this a repair to an.existing well: . . ❑Yes . or ItNo 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Smndards'and that a copy
If this is a repair,fill out known well construction in•formation and explain the nature of the of this 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 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 additional pages if necessary.
drilled:NA 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:'20.3
For multiple wells list all depths ifdifferenr(example-3@200'and 2@100') . . Submit this GW-1 within 30 days of well completion.per the.following:
Not Encountered ) 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 level is above casing,use
11.Borehole diameter: 4.25 (in.) 24b. For Injection Wells:Copy to•DWR,Underground Injection Control(IUC)
Piogram,1636 MSC,Raleigh,NC 27699-1636
12.W Auger.
ell construction method: 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
.. 13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6'-2018