GW1--04139_Well Construction - GW1_20230623

. WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor Information: I
Connor Cordingley :14:WATERZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4568-A
ft. ft.
NC Well Contractor Certification Number 15:OUTER CASING(for multi_cased wells)OR LINER(if app licable)
A.C. Schultes of Carolina, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
ft. ft. in.
Company Name WS
0700 79 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.) 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 ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
(!Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19..SAND/GRAVEL PACK(if applicable). '
❑Aquifer Storage and Recovery ESalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
-
❑Experimental Technology ❑Subsidence Control ft. ft.
i
DGeothermal(Closed Loop) ❑Tracer 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 grain size,etc.)
245 ft. 270 ft• Clay with Sand
4.Date Well(s)Completed: 6.4.23 Well ID# Hale Swamp 270 ft. 290 ft. Clay,Sand&Limestone
5a.Well Location: 290 ft• 310 ft• Sand&Hard Limestone
Tidewater Grain 310 ft• 340 ft. Sand Layers
Facility/Owner Name Facility ID#(if applicable) ft. ft. t[.-i (
''F'j'`y I! '?
Straight Road, Merrit ft. ft.
ft. ft. V
++1.IV „.j ; Z023
Physical Address,City,and Zip
Pamlico
intei$7+i15k....l : ,, v.ate,.rg LC.r
County Parcel Identification No.(PIN) FIVIGi'nO.7
5b.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 6 ' 3
6.Is are the wells: CJPermanent or ❑Tern ara Si of rti ed ell Contractor �� Date
Is(are) O P ry
By signing this form,I hereby cert fy that the well(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,Jill 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 2@100')
10.Static water level below top of casing: 9 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use••+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.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
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 61 1
'
13b.Disinfection type: Amount: 1 l
Pae_ a
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018