WI0400631_Well Construction Record(s) (GW-1)_20241120

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Wesley J. Sorrells 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3577
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Terraquest Environmental Consultants FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eother al closed-loo
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. fL in.
Geothermal(Heating/Cooling Supply) [IResidential Water Supply(single) ft. fL in.
hidustrial/Commercial Residential Water Supply(shared) 18.GROUT
hTijzation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. Portland Pour
Monitoring ORecovery ft. ft.
Bentonite Pour
Injection Well:
ft. ft.
Aquifer Recharge QlGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 01 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
X Aquifer Test QI Stormwater Drainage ft. ft. N o.2 Sand Pour
Experimental Technology 01 Subsidence Control
Geothermal(Closed Loop) 13Tracer 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.
ft. Ft. Concrete
4.Date Well(s)Completed: 11/12/24 Well ID#I NJ 1-3 ft. ft. Gravel
5a.Well Location:
Ricks Food Mart 00-1-0000004009
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1122 Morhead St. Burlington NC
Physical Address,City,and Zip
ft. ft.
Alamance 133049 21.REMARKS
County Parcel Identification No.(PIN) Probe to ' ' '
e e retract
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36.082669 N -79.429541 W 6 �'��
11/19/24
6.Is(are)the well(s)1IPermanent or XOTemporary Signature of CertifiJdWell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:3 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20 (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:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:2.25 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
direct push above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
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: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016