HomeMy WebLinkAboutGW1-2021-03244_Well Construction - GW1_20210628 i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
FROM TO DESCRIPTION I
Well Contractor Name
A - 2581 ft t.
. f ft.
NC Well Contractor Certification Number 15.;OUTER CASING for:multi-cased'wells ORiLINER ifa livable
GEOLOGIC EXPLORATIOF rt021 FROM TO DIAMETER THICKNESS MATERIAL
wl �. Q� 0.0 ft. 50.0 ft. 6.0 SCH 40 PVC
Company Namegg1c�9�� 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#' pIO FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits k%U U�`awlull p mince,etc.) 0.0 ft. 69.0 fl- 2.0 F tn' SCH 40 PVC
3.Well Use(check well use): ft• ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER] i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 69 0 ft. 79.0 rt- 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,GR0UT- I x
❑lrrl ation ❑Wells>100,000GPD FROM TO MATERIAL! IEMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ff 49.0 ft- PORTL4NDSENTONITE I SLURRY
OMonitoring ❑Recovery 0.0 ft- 50.0 ft- PORTLAND BENTONRE SLURRY
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
193 SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 65.5 ft- 79.0 ft- 20-46 { FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft. i d
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock a rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0.0 ft- 14.0 ft- I ;RED S�LTY CLAY/BOULDERS
4.Date Well(s)Completed: 05/26/21 Well ID# MW-10BR 14.0 ft- 28.0 ft- I BLACK SILTY SAND
5a.Well Location: 28.0 ft- 47.0 ft• I PWR
DAN RIVER STEAM PLANT 47.0 rr. 7g 0 fl- ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
524 SOUTH EDGEWOOD ROAD EDEN 27288 R. ft.
Physical Address,City,and Zip ft. ft.
ROCKINGHAM 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-49.0-65.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
360 29' 29.55" N 790 43' 11.04" W
06/09/21
6.Is(are)the well(s): ITPermanent or ❑Temporary Signature ofCertified Well Contractor i I Date
By signing this form,]hereby certify that the wells) vas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 01C.0100 or ISA 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 rv""ell 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: 79•0 (ft.)
For multiple wells list all depths ifdii ferem(example-3@200'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
25.0 24a. For All Wells: Original for�to Dil ision of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifivater level is above casing,use"+"
11.Borehole diameter: 12.0/6.0/7.875 (in) 24b. For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/AIR
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
ty environ
(i.e.auger,rotary,cable,direct push,etc.) counmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells DroducinS'iover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: 1
{
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018