GW1-2022-03278_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR i
14.WATER ZONES l 1
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098 ft. it. 1
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICK' S MATERIAL
ft. ft. i. in.
Company Name
16.INNER CASING OR TUBING eothermal 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. 5.0 ft- 2.0 i"• SCH 40 PVC
3.Well Use(check well use):
ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft. 15.0 ft. 2.0 t"' .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 ❑Wel Is> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 ft' PORTLANDaENTONITE SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 4.0 ft- 15.0 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) ❑Other(explain under 421 Remarks) FROM I TO DESCRIPTION color,hardness,soiltrock type,gimin size,etc.
0.0 ft• 0.5 ft. ASPHALT
4.Date Well(s)Completed: 02/1 1/22 Well ID# MW-4 0.5 ft. 8.0 ft. WHITE/GRAY SAND
5a.Well Location: 8.0 ft• 12 0 rt• WHITE CLAY
ACME CLEANERS 12.0 ft• 15.0 ft• TAN CLAY
Facility/Owner Name Facility ID#(if applicable) ft, ft. --.
200 SOUTH BODDIE STREET NASHVILLE 27856
Physical Address,City,and Zip
rt. ft.
MAR
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:
(if well field,one lat/long is sufficient) 22.Certification:
350 58' 24.80" N 770 58' 06.24" W j � 02/18/22
6.Is(are)the well(s)• (EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that(he well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a coPt,
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 we//owner.
repair under#2I 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 pageto 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)
Far multiple wells list all depths ifelii ferent(example-3@200'and 2@100')10. Submit this GW-1 within 30 days of well completion per the following:
7•0 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if "*" i
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy toDWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER i
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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018