GW1--05860_Well Construction - GW1_20230912

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I
Jeovany Gutierrez Bautista 14.WATER ZONE5" p a
Well Contractor Name FROM TO • DESCRIPTION
' ft. ft. f
4125-A ft. ft. I I
NC Well Contractor Certification Number 15:OUTER CASING(for multi-cased'.wells)OR LINERSif ap licable)
A.C. Schultes of Carolina, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I, in.
Company Name
•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. 1 , in.
Water Supply Well: n 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ClAgricultural ❑Municipal/Public ft. ft. in..
❑Geothermal(Heating/Cooling Supply) ❑Residential 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. I; '
DMonitoring ❑Recovery ft. ft.
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 . ft. ft.
❑Experimental Technology • ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional'sheets if necessary) •- . '
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrocktype Amin size,etc.)
240 ft' 260 ft. Tight Clay
4.Date Well(s)Completed: 8/22/23 - Well ID# 2 260 ft• 290 ft' Clay,Trace of Sand
5a.Well Location: 290 ft. 320 ft. Clay, and,Trace of Lignite
Butterball Feed Mill 320 ft 340 ftClay 5 ,,_; i V C.Li
Facility/Owner Name Facility ID#(if applicable) ft. ft. , SEP rit. 2,1
01
5604 Hwy 24, Turkey, NC ft. ft.
Physical Address,City,and Zip ft. ft. i; r F L{+i
rii ad.d 4l C
21.REMARKS_:. „- . Ink'. :.^ r/z+rc�';.34a
Sampson
County Parcel Identification No.(PIN) I'
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W w,,, �1 f l 9-5-03
6.Is(are)the well(s): CJPermanent or ❑Temporary aure• A Il •Co.actor Date
igning� I hereby cert&that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or it No 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
r
9.Total well depth below land surface: 70 (ft.) I,
different
For multiple wells list all depths if (example-3@200'and 2@!00') Submit this GW-1 within 30 days of well completion per the following:
52.25 24a. For All Wells: Original foirm 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•'+'•
11.Borehole diameter: 17 (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 Ope I-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.Far Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: •
.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource Revised 6-6-2018