GW1-2022-03277_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 3098 rt. ft. E
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loon)
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.UIC,County,Sale,Variance,etc.) 0.0 fr. 5.0 ft. 1 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETERS I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft- 15.0 ft' 2.0 1O" .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R. in..
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 3,0 ft' PORTLANDBENTONRE SLURRY
(EMonitoring ❑Recovery ft. R.
Injection Well:
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EM PLACEM ENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft- 15.0 ft- 20-40 FINE SILICA SAND
I]Experimental Technology ❑Subsidence Control ft. ft.
❑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/mck type,grain siu,etc.
0.0 e• 0.5 fr• ASPHALT
4.Date Well(s)Completed: 02/10/22 Well ID# MW-5 0.5 ft• 1.0 ft• GRAVEL
5a.Well Location: 1.0 ft' 3.0 ft' GRAY SAND
ACME CLEANERS 3.0 fr• 6.0 ft• BLACK SAND
Facility/Owner Name Facility ID#(ifapplicable) 6.0 tt• 13.0 ft. C WHITE/GRAY CLAY
200 SOUTH BODDIE STREET NASHVILLE 27856 13.0 ft• 15.0 fL ORANGE/TAN CLAY
Physical Address,City,and Zip ft. ft.
NASH 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-4;0 FEET - - - -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �!MAR
(if well field,one lat/long is sufficient) 22.Certification: ftf
350 58' 24.80" N 770 58' 06.24" W 02/18/22
�ju rt� 22-
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date -
By signing this/brm,I hereby cerlify that the trell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑YeS or INNo I5A NCAC 02C.0100 or 15A NCAC 02C'0200 Well Construction Standards and that a copy
/%this is a repair,fill out known well construction in(brmalion and explain the nature of the of this record has been provided to the uve//owner.
repair under i121 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 if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15.0 (ft.)
For mnhiple wells list a//depths ifdijjerem(example-3 200'and 1 rt 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 7.0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above caring,use"+-"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy to 6WR,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 departmdht of the county where installed
FOR WATER SUPPLY WELLS ONLY: I
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
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018