GW1-2023-02568_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 5 f` >12 ft Upland next to wetland
ft ft i
NC Well Contractor Certification Number 15.OUTER CASING for inulti-cased'wells OR LINER if a livable
Soil & Environmental Consultants, PA FROM TO DIAMETER THICKNESS MATERIAL
+3 ft 7 ft- 2 in. I Sch 40 JPVC
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: NA FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 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) ❑Residential Water Supply(single) ft 7 ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 2 ft concrete pour
IlMonitoring ❑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#21 Remarks) FROM To DESCRIPTION tutor,hardness soillrock rain s' etc.
)0 It. 0.5 ft Loam, 10 YR 3/2
4.Date Well(s)Completed: 1-26-23 Well ID# OW-56 0.5 ft 1.5 ft Clay Loam,10 YR 4/3
5a.Well Location: 1.5 ft 5 ft Clay, 10 YR 4/4,10 YR 6/2
Chemours 5 ft 12 ft Clay,dark gray,orange mottles,
Facility/Owner Name Facility ID#(if applicable) ft ft
ft ft F.
Physical Address,City,and Zip ft ft v
Cumberland 21.REMARKS
Prepacked well screen
County Parcel Identification No.(PIN) 1 5 _ 4,^
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �7777r r r '
(if well field,one lat/long is sufficient) 22.Certification:
Lat: 34.854401 N Long: -78.831217 W Dq"y Z3
6.Is(are)the well(s): nPermanent 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 MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has beenprovided 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:u^ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
8' 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
Ifwater level is above casing,use"+"
II.Borehole diameter: 6 in (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
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
Ili