GW1-2021-00749_Well Construction - GW1_20210401

t
i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: o- '
1.Well Contractor Information:
BRIAN THOMAS r aN 14.WATER ZONES
Well Contractor Name v.� FROM TO DESCRIPTION ft ft t
A - 2581 fI. ft. f i
NC Well Contractor Certification Number ry���$ 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION M ;stun�rQWf5`�J FROM TO DIAMETER THICKNESS MATERIAL
t 0.0 ft• 45.0 ft• 6.0 I in• SCH 40 PVC
Company Name �,y'� Jam`•
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well ctn.siruction permits(i.e.UK',Comuy,State.Variance,etc.) 0.0 ft. 50.0 ft. 2.0 I in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER ;SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 50.0 ft. 65.0 It' 2.0 in. j .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL' EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 45.0 ft. PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 48.0 ft. 77.0 tc 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. R.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) 100ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
0.0 tt• 5.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 03/22/21 Well ID# MW-11 D 5.0 IL 13.0 ft. BROWN SILTY SANDY CLAY
5a.Well Location: 13.0 ft' 28.0 tf TAN SILTY SAND
CHARAH - BRICKHAVEN 28.0 tt• 41.0 tt• PWR
Facility/Owner Name Facility IDN(if applicable) 41.0 tt' 200.0 tt' ROCK
1271 MONCURE FLATWOOD ROAD MONCURE 27559
Physical Address,City.and Zip ft. ft.
i
CHATHAM 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL-45.0-48.0 FEET
AQUA GUARD;- 77.0-200.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 59' 21.90" N 790 02' 19.50" W �r,,;t, ;�jk�r--
03/24/21
6.Is(are)the well(s): IWIPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,1 herehy certify drat the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or T]No 15A NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cape
//this is a repair,Jill out known well construction information and explain the nature of the gf1hi.s record has been provided to the well ti,wner.
repair under.-21 remarks section or on the back g/'this Jorm.
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 necessan'.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 65.0
/�br mutuiple sells list all depths ifdiJJerem(example-3@200'and 2@100) Submit this GW-I within 30 days of Well completion per the following:
31.0 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
/fearer level is above cawing,use'
6.0/10.0 24b. For Injection Wells:Copy to DWR, Underground Injection Control (IUC)
11.Borehole diameter: (in.)
Program, 1636 MSC,Raleigh,NC 27699-,1636
12.Well construction method: AIR
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 ove I60,0001GPD: Copy to DWR.CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
k
13b.Disinfection type: Amount: p
C
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018