GW1-2021-00810_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jonathan R. Grubbs 14.WATER ZONES
%%'ell Contractor Name FROM TO DESCRIPTION
ft. fG
3001
ft. I FL
NC Well Contractor Certification Number 15.OUTER CASING for mWtitased weLLa OR LINER dv Gcabk
Terraquest Environmental Consultants, P.C. FRonl To Damerea Ti- cRNEss nArea AL
Company Name FL 12 i sehd 40 1 PVC
W M 0501411 16.INNER CASING ORT'UBING d dow
el-loop)
2.Well Construction Permit q: FROM TO DIAMereR THICKNESS MATERIAL
List all applicable well consnuctron permus(i.e_UR',('ounry.S'rare, {nuance,ere,) ft. fL in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 f. 20 h. 2 sm 0.010" sehd 40 1 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 5 ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Ilrialion ❑Wells> 100,000 GPD FROM TO I MATERLM1L EMPLACEMENTMETIIOD&AM1IOONr
Non-Water Supply Well: 0 f. 1 fic portland pour
OMorraming ❑Recovery 1 D. 3 fL bentonite pour
Injection Well:
ft. A
❑Aquifer Recharge ❑Groundwater Remedialion
19.SAND/GRAVEli PACK ,fa tale
❑Aquifer Storage and Recovery ❑Salinity Darner FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3 R 20 R no 2 filter sand pour
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) El Tracer 20.DRILLING LOG bittach additional shreb if aemu
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) FROM TO DESCRIPr[ON rolor,hardness,soitrack ore,grain ore,etc.)
0 ft. 5 fL abdt red/org clay high plasticity minor mica
4.Date Well(s)Completed: 2/3/21 Well IDN MW20 5 ft. 10 fL light brwn clay med sand Tried plast.minr fg sand
5a.Well Location: 10 FL 15 FL light brwn mg sand mod clay high moist
Bunn Exxon 0-015307 15 ft' 20 fL light gray clay with cg sand
Frieda,Owner Name Facility lDklifapplicable) ft. IL
300 MAIN STREET, BUNN NC 27508 ft. fL
Physical Adrhess,City,and Zip ft. R
FRANKLIN 2820-05-8275 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iar/long is sufficient) 22.Certification:
35.96030 N. -78.25358 W. ��
2/8/2021
6.Ishire)the well(s): 111'ermanent or OTemporar, - - Signature ofCcatified Well Contra, r Date
6 ug thu fomt f herehr cert that the well(r/was/mere/,onertsred m accordonce xath
FEB
15 U 7.Is this a repair to an existing well: ❑Yes or MNo AC 02C.0/00 or 15A NCAC 02C.0200 Wefl Construcuon Standards and that a copy
If this is a repair fill out knomn well construction information and erp/mn the nature of the of this record has been provided to then ell owner
repair under-21 remarks section or an the hack of1hi.s form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the snore h'oil'may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovet'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20 (ft') Submit this GW-1 within 30 days of well completion per the following:
I'ar multiple well,list all depths jdJferent 3n200 and 21i,100'I
24a. For All Wells: Original form to Division of Water Resources (DWI ),
10.Static water level below top of casing: (f') Intormation Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
Ifmater level¢above caring,u e
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells: Copy to DWIC Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: solid stem auger
24c.For won Supple and department Geothermal Return Wells:Copy to the
(i e.auger,rowry,cable,direm push,etc.) count),environmental health department of the county where installed
FOR WATER SUPPLY NY ELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Cop}'to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-I611
Ida.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form G W-1 North Carolina Deparmucut of Environmental Quality-Division of Water Resources Revised 6-6-2018