GW1--05694_Well Construction - GW1_20240920

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Matt Steele 14.WATER`ZONES - '
FROM TO DESCRIPTION
Well Contractor Name 37.86 ft. 40 ft. I
4548 ft. ft.
NC Well Contractor Certification Number .15.OUTER CASING(for multi-cased wells)OR LINER(if ap ►icable).
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. 'in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 20 ft. 2 i in. Sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN j ,
Water Supply Well: FROM TO . DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 ft. 40 ft. 2 in. 0.010 '°' Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft' ft. in.
❑Industrial/Commen ial 0 Residential Water Supply(shared) 18.GROUT_
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 ft' 16 ft* grout pour
Non-Water Supply Well:
BMonitoring ❑Recovery 16 ft. 18 ft. bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier 18 ft. 40 ft. #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilrock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft• 0.6 ft. Gravel
05/06/2024 GMW-1 0.6 ft. 17 ft. Fine sand
4.Date Well(s)Completed: Well ID#
17 ft. 32 ft. 1 Silty sand
5a.Well Location: 32 ft. 35 ft. i Silty sand
Carolina Trace Country Club Pending 35 ft- 40 ft.
Silty sand
Facility/Owner Name Facility ID#(if applicable)
ft. ft. +
NC Highway 87,Country Club Drive,Traceway North, Sanford,NC
ft. ft. F -., :7;" S "'N
Physical Address,City,and Zip 21.REMARKS --' # " • -. tF 3 1
Lee 9660-53-7655 SAPS
County Parcel Identification No.(PIN)
I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: lr'1".:7 t C_• /'"'r�rsa;i;; Liost
22.Certification � `�
(if well field,one lat/long is sufficient) /Y ' lY'�'Cu' + ;a
35.4083805 N 79.1147083 W ' 05/06/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or 0 Temporary By signing this form,I hereby cerhfy''that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:40 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following: 1
37.86 Division of Water Resources,Information Processing Unit,
10.Static water•level below top of casing: (ft) eo
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
Solid Flight Auger
12.Well construction method: construction to the following: :
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county'health department of the county where
constructed. 4
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013