GW1-2021-03245_Well Construction - GW1_20210628

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATERZONES c,
Well Contractor Name FROM TO DESCRIPTION I
A - 2581 rt. a. 1
2 q 202� ft. ft.
NC Well Contractor Certification Number y�,N V {� 15.OUTER CASING foi mul1-gsedlells OR LINER' if a livable
GEOLOGIC EXPLORATION lOg�eCo� FROM TO DIAMETER THICKNESS MATERIAL
Company Name al
0.0 ft. 38.0 ft- 6.0 i" SCH 40 PVC
�11frn' fO�R
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 47.0 ft- 2.0 f in. SCH 40 PVC
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: 17.'SCREEN ! `
FROM TO DIAMETER 41 SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 47.0 ft' 57.0 ft 2.0 in. `,010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) lg•!GROUT
❑Irri ation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft 35.5 ft' PORTLAND BENTONITE SLURRY
MMonitoring ❑Recovery, 0.0 ft. 380 ft' PORTLAND BENTONITE SLURRY
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK I(if applicable)
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 43.0 ft- 64.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifinecessa
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft. 10.0 ft. RED SILTY CLAY/BOULDERS
4.Date Well(s)Completed: 05/25/21 well ID# MW-11 BR 10.0 ft- 18,0 ft- I TAN SILTY SAND
5a.Well Location: 18.0 ft' 26.0 ft' I PWR
DAN RIVER STEAM PLANT 26.0 ft• 123.0 ft- I ROCK
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
524 SOUTH EDGEWOOD ROAD EDEN 27288 ft. ft.
Physical Address,City,and Zip rt. ft.
ROC KING HAM 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-35.5-43.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
TIME RELEASE PELLETS��64.0- 123.0 FEET
(if well field,one lat/long is sufficient) 22.Certification:
360 29' 29.55" N 790 43' 11.04" W cL%'G"'. 06/09/21
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6.Is(are)the well(s): 051'ermanent or ❑Temporary Signature of Certified Well Contractor I Date
By signing this form,I hereby certify that he ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or 15A 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 well owner.
repair under 921 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: 57.0 (ft.
For multiple wells list all depths ijdifferen1(example-3@100'and 1@100') ) Submit this GW-1 within 30 days 1of well completion per the following:
10.Static water level below top of casing: 23.5 (1t) 24a. For All Wells: Original form ito Division of Water Resources (DWR),
ljwater level is above casing,use^+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: 12.0/6.0/7.875 (i") 24b. For Infection Wells:Copy tot DWR,Underground Injection Control(IUC)
AIR Program,1636 MSC,Raleigh,NC 27699-1636
AUGER
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
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018