GW1-2021-06984_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: h
JOHNNY BURR 14.WATER ZONES
Well Contractor Name gam' - ' �; FROM TO DESCRIPTION
y
rt. ft.
A - 3098 p V 21 it. it
NC Well Contractor Certification Number `��,y 1 f� J �O 15..OUTER CASING(tor multi-cased wells)OR LINER(if applicable)
GEOLOGIC EXPLORATION ,,f,, ,�.-J t:)',�i FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name ii1Ui, nnr't;0'il
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft. 10.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): fL ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft' 20.0 ft. 2.0 in., .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.!
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT.
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 IL 6.0 it' PORTIAND 9ENTONITE SLURRY
19Monitoring ❑Recovery
Injection Well:
ft. it.
❑Aquifer Recharge. ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a 1icablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 8.0 IL 20.0 It 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG'attach additional sheets if necessary)
-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTIONcolor,hardness s7rock e rain size,etc.
0.0 II• 1.0 It ASPHALT
4.Date Well(s)Completed: 03/31/21 well ID# MW-16R 1.0 II• 7.0 It. RED/ORANGE CLAY
5a.Well Location: 7.0 ft 20.0 It. RED/BROWN SILT
SPEEDWAY - 6983 rt. ft
Facility/Owner Name Facility ID#(if applicable)
850 CAPITAL BLVD RALEIGH 27603
Physical Address,City,and Zip fL ft.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITESEAL- 6.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one)at/long is sufficient) 22.Certification:
350 47' 32.76" N 780 38' 30.01" 04/01/21
6.Is(are)the well(s): NPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l!9No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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: 20.0 (ft.)
Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@700� )
12.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter:
$.0 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
�
AUGER Program,1636 MSC,Raleigh,NC 276994636
12.Well construction method: 24c.For Water Supply and Open-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.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources!. Revised 6-6-2018