GW1-2023-01577_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Matthew Cunningham 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
- 4217-A 320 ft• 360 ft• [Sandil
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Christian & Pugh Well Drilling & Service FROM TO DIAMETER Till
MATERIAI.
Company Name
0 ft- 330 ft- 4.5 SDR-17 JPVC
235284 16.INNER CASING OR TUBING eothermal closed-loot)).
2.Well Construction Permit th FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 330 ft. 350 ft. 2 in. SCH 40 Galvanized
3.Well Use(check well use): ft. ft. in.
Water Supply Well: -17.:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 350 ft. 360 "L 2 in.
.020 304SS Stainless
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18:GROUT -
_ Irr1 ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tr. 20 tt. Bentonite Poured
Monitoring (Recovery
Injection Well:
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Dsalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage It. tt.
Experimental Technology Subsidence Control It. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type, rain size,etc.
0 ft• 20 ft• Top; Clay, Sand
4.Date Well(s)Completed: 1-27-2023 Well ID# 20 ft. 180 ft• Mud, Shell
Sa.Well Location: 180 rt. 210 ft• Black Sand
Katie Schemmel 210 ft• 320 ft Clays - White/Re d
Facility/Owner Name Facility ID#(ifapplicable) 320 ft. 360 ft- Sand '>
20 Wells lane, Gates, NC 27937
FEB
Physical Address,City,and Zip ft. ft. C t
Gates 21.REMARKS "
County Parcel Identification No.(PIN) y >`;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 40ertnifflJ/36 31 54.2 N -76 45 15.1W 01/30/2023
6.Is(are)the well(s)ox Permanent or Temporary Certi e We11QD ractor Date
By si ning this form,! ereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or DNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/fthis is a repair•fill out known well construction information and eanlain the nature ofthe copy of this 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 site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: nf1P SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 360 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells•list all depths ifdii ferent(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12. Mud Rota above, also submit one copy of,this form within 30 days of completion of well
(i.e,auger,rotary,cable,direct push,Well construction method etc.) Rotary construction to the following:
.e
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20+ Method of test: Airlift 24c. For Water Supply& Iniection Wells: In addition to sending the form to
Ca CIO 2 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 30 ounces completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resoui&ces Revised 2-22-2016

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