GW1--05862_Well Construction - GW1_20230912

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeovany Gutierrez Bautista .14.WATER ZONES ' ,:4P: ' - _,• '
Well Contractor Name FROM TO DESCRIPTION
126 ft. 160 ft. f
4125-A ft. ft.
1, I
NC Well Contractor Certification Number 15:OUTER CASING(for multi4ased`wells)OR LINER(if ap licable)
A.C. Schultes of Carolina, Inc. FROM TO DIAMETER THICINESS MATERIAL
0 ft. 32 ft. 12 I { in. SCH 40 Black Steel
Company Name
•16:INNER CASING OR TUBING(geothermal closed-loop) ,
2.Well Construction Permit#: FROM , TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennies(i.e.UIC,County,State,Variance,etc.) 0 ft. 126 ft• 4.5 i in• SDR-17 Certa-Lok
3.Well Use(check well use): 160 ft• 170 ft• 4.5 I In' SDR-17 Certa-Lok
17.SCREEN ' ' `
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 126 ft. 160 ft. 4.5 1°' .032 PVC SDR 17
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 126 ft• i"
•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT '
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply W --- / ft. ft. Slurry, , 4 CY
❑Monitoring .it- -. k ""o ft. ft. ,
Injection Well:
❑Aquifer Recharge S E P 1 2 Zoundwater Remediation D. ft.
19.SAND/GRAVEL PACK(if applicable)•. - . "
❑Aquifer Storage and Re ovIrer'I Rr„M.woy itl x Iarrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test Inf'R. pv oisoL JStormwater Drainage 80 ;ft. 170 ft• #I A
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)'
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft' 10 ft• Red sand coarse
4.Date Well(s)Completed: $/22/23 Well ID# 2 10 it 20 ft. Mostly'coarse sand
5a.Well Location: 20 ft. 30 ft. Sand,clay balls,some red stone
•
Butterball Feed Mill 30 ft. 40 ' ft. Clay,some sand,organics
Facility/Owner Name Facility ID#(if applicable) 40 ft. 80 ft. Blue clay,some sand
5604 Hwy 24, Turkey, NC 80 it 90 ft• Clay, :and,black brittle wood
Physical Address,City,and Zip 90 ft. 100 ft. Clay,sand,some lignite
Sampson 2T.REMARKS
County Parcel Identification No.(PIN) I •
'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one lat/long is sufficient) 22.Certification:
N W •
° ,593
6.Is(are)the well(s): (Permanent or ❑Temporary • e f ed We : ctor ; . Date
By signing this form,'hereby cert fy thai.the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or lNo 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: 170 (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:
10.Static water level below top of casing: 52.25 (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: 17 (in.) 24b.For Injection Wells: Copy to I)WR,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 departineht 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 27699-1 61 1
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