GW1--04138_Well Construction - GW1_20230623

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,
1.Well Contractor Information: I
Connor Cording le
y 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
240 ft. 300 ft.
4568-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
A.C. Schultes of Carolina, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 60 ft. 16 ' in' SCH40 STEEL
WS 07001179 16.INNER CASING OR TUBING(geothermal closed-loop) '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 240 ft. 8 ' '"• SDR17 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 240 ft• 300 ft. 8 in' .030 SDR17 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
MIrrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 60 ft. Cement Tremmie
❑Monitoring ❑Recovery 0 ft. 80 ft. Cement Tremmie
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable).
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO , MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑StonnwaterDrainage 80 ft• 340 ft. Well Gravel 1A Tremmie
❑Experimental Technology ❑Subsidence Control ft. ft.
DGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) '
DGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
0 ft. 10 ft. Topsoil
4.Date Well(s)Completed: 6.4.23 Well ID# Hale Swamp 10 ft. 60 ft. Fine Sand&Shells
5a.Well Location: 60 ft. 70 ft. Grey Clay
Tidewater Grain 80 ft 120 ft. Clay,Shells,&Sand p--,x ,,..,e.4„ .__,
Facility/Owner Name Facility ID#(if applicable) 120 ft. 160 ft• Clay&Shells i' '"r:-L CI Vyc
Straight Road, Merrit 160 ft. 200 ft. Sand JUN `? E 2023
Physical Address,City,and Zip 200 ft. 245 ft. Limestone
Pamlico 21.REMARKS - ' tflfmrn.- ^1 ?r .7 is,; :Jr.
County Parcel Identification No.(PIN) Dlt:r`OZOG
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.098765 N 76.668640 W
Is(are)the veil s: PJPermanent or ❑Tern orar Signature 3
� r'ed Well Contractor Date
6. s(a e) O p y
By signing this form,I hereby certify that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 303 (ft) 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 2Q100)
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9 24a. For All Wells: Original fonn 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"-I-•• I
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II.Borehole diameter: 15 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test: 11
13b.Disinfection type: Amount: �Q (%e.I 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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