GW1-2023-02567_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Donald Wells 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3583-A 9 ft >12 ft Upland next to wetland
ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-ed wells OR LINER if a licable
Soil & Environmental Consultants, PA FROM TO DIAMETER THICKNESS MATERIAL
+3 ft 17 ft. 12 in- ISch 40 JPVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: NA FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ire..YIIC`County`SialJ 1!ar,.f4nBe,etc.) ft ft. in.
3.Well Use(check well use):
Water Supply Well: APH 1 9 1t�3 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 7 ft 12 ft- 2 in. 0.01 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply)' " '{7Res�eiitial Water upply(single) ft ft in.
6i.+• -; 7
❑Industrial/Commercial ❑Res
'ilntii Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 2 ft concrete pour
InMonitoring ❑Recovery 2 ft 4 ft bentonite pour
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4 ft 12 ft #2 Sand JPour
❑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.soitfrock type min size,etc.
0 ft 0.5 ft Loam, 10 YR 3/2
4.Date Well(s)Completed: 1-26-23 Well ID# OW-54 0.5 ft 1.8 ft Silt Loam,7.5 YR 4/4
5a.Well Location: 1.8 ft 2.5 ft- Sandy Clay Loam,10 YR 5/6
Chemours 2.5 ft 3.6 ft. Sand, 10 YR 6/6
Facility/Owner Name Facility ID#(if applicable) 3.6 ft 7.4 ft Sandy Clay Loam, 10 YR 6/6,10 YR 5/1
7.4 ft 12 ft. Sand, 10 YR 5/8,5 YR 5/8,10 YR 5/1
Physical Address,City,and Zip ft ft
Cumberland 21.REMARKS
County Parcel Identification No.(PIN) Prepacked well screen '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification:
Lat: 34.851882 N Long: -78.829083 N
41-3- Z3
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A 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 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:- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12 (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
12' 24a. For All Wells: Original form to Division of Water Resources (DWR),
/J water level is above casing,use"+
ff Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"
11.Borehole diameter•• 6 In (in.) 24b.For lniection 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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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