GW1-2022-03281_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
ft. ft. l
A - 3098 ft. ft.
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-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 55.0 ft. 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft- 15.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 3.0 ft- PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
fr. ft.
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft- 15.0 rt. 20-40 FINE SILICA SAND
DExperimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hamdness,soil/mck type,prain size,etc.
0.0 rr• 1.0 a• GRAVEL
4..Date Well(s)Completed: 02/10/22 Well ID# MW-1 1.0 fr. 80 ft. GRAY SAND
5a.Well Location: 8.0 ft. 9.0 it. GRAY SANDY CLAY
ACME CLEANERS 9.0 rt• 150 rt• TAN/YELLOW SAND
FacilityiOwner Name Facility ID#(if applicable)
ft. ft.
200 SOUTH BODDIE STREET NASHVILLE 27856 n. rt. MAR 14 202?
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:
(if well field,one[at/long is sufficient) 22.Certification:
350 58' 24.80" N 770 58' 06.24" W �""' 02/18/22
6.Is(are)the well(s): IEPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)Bras(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!9No I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lt'thts is a repair,fill out known well construction information and explain the nature oflhe oflhis record has been provided to the well owner.
repair under 921 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 1 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 multiple hells•list all depths ifdi&reni(example-3@200'and 2@100') 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),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If hater level is above casing,use"+"
IL 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-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 WqIL NO, over:100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,INC 27699-1611
13a.Yield(gpm) Method of test:
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13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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