GW1-2021-00747_Well Construction - GW1_20210401

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
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BRIAN THOMAS 14.WATER ZONES i
Well Contractor Narne ® ,�„ FROM TO I DESCRIPTION
ft. I
A - 2581 APR X 1 2021 rt. it. ;
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION pro"-�slleh U1�T1 FROM ft TO it DIAMETER
ftn THICKNESS MATERIAL
1�fr �1 r i
Company Nam _e �- '
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER: I THICKNESS I MATERIAL
List all applicable well conrtruclion permits(i.e.(/IC County.State, Variance.etc.) 0.0 ft. 26.0 ft• 2.0 :in. SCH 40 PVC
3.Well Use(check well use): ft. ft, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER iSLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 26.0 e. 36.0 ft' 2.0 in. ;.010 SCH 40 PVC
❑Geothermal(Healing/Cooling Supply) ❑Residential Water Supply(single) ft. fr. in.
Olndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Olrri atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 it. 19.0 i[. PORTtAND BENTONITE SLURRY
&Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge &Groundwater Remediation
19.SAND/GRAVEL PACK(ifapplicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 22.5 rt 36.0 rt 20-40 FINE SILICA SAND
OExperiinental Technology OSubsidence Control
❑Geothermal(Closed Loop) ❑Tracer 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,gnin size,etc.
0.0 it 7.0 it RED SILTY CLAY
4.Date Well(s)Completed: 03/17/21 Well ID# MW-9 7.0 fr 30.0 it TAN SILTY SAND
5a.Well Location: 30.0 rL 36.0 ft' PWR
CHARAH - BRICKHAVEN rt• rt•
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1271 MONCURE FLATWOOD ROAD MONCURE 27559
Physical Address,City,and Zip ft. ft.
CHATHAM 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 19.0-22.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one[at/long is sufficient) 22.Certification:
350 59' 84.71" N 790 02' 02.67" W 03/24/21
6.,Is(are)the well(s): &Permanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing this frtrni,l herehv certlJj'that the ivell(s)rras(irere)constructed in accordance frith
7.Is this a repair to an existing well: OYes or &No I5A N('A('02('.(100 or l5A NCAC 02('.0200 6Ve/l C'otistrtiction StandarcLr and that o cogv
if dti.v i.v a repair,Jill our known well convtntction itrforntatioti and e.rplaitr the nature oj'dre of this record has been provided to the well owner.
repair snider=21 reinarkv section or on the back of this forin
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 I GW-I 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: 36.0
Fbr nwhiple wells/ist till depths ifdi/)'event(example-1 rr 20 and 2 ri.100') Submit this GW-1 within 30 days of well completion per the following:
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
//'voter level is above casing,use "
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER 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,INC 27699-I611
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13b.Disinfection type: Amount:
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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