GW1-2022-05400_Well Construction - GW1_20220311

0
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
rt. rt.
A - 3098
ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft- 15.0 ft- 2.0 'n' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FR SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15.0 ft- 25.0 ft. 2.0 1O' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
[ Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri at10n ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 8.0 tt' PORTLAND BENTONITE SLURRY
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 13.0 ft- 25.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
0.0 ft• 6.0 it• RED SILTY CLAY
4.Date Well(s)Completed: 10/09/21 well ID# CLF-21-18 6.0 ft• 14.0 ft. ORANGE/BROWN SILT
5a.Well Location: 14.0 ft' 25.0 ft' i BROWN SILTY CLAY
MARSHALL STEAM STATION ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
8320 NC HIGHWAY 150 SHERRILLS FORD 28673 ft. ft.
Physical Address,City,and Zip ft. ft. J.: -
CATAWBA 21.REMARKS 6'
County Parcel Identification No.(PIN) BENTONITE SEAL-8.0-13.0 FEET
***PIEZOMETER***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient) 22.Certification:
350 35' 37.55" 800 57' 57.36"
N W L..1 1'0/14/2.1 . .
6.Is(are)the well(s): 291'ermanent or ❑Temporary Signature ofCertified Well Contractor Date
By.signing this form,I hereby certify that the wel(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or fflNo ISA NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under 421 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 25.0 (ft.)
For multiple wells list all depths ifdiemm(example-3@200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
11.0 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
/jwaier level is above casing,use"+"
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy fo DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loon 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 producint l over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource is Revised 6-6-2018