GW1-2022-03337_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD
C• (GW-1) For Internal Use only: E
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES 'i i
Well Contractor Name FROM TO DESCRIPTION
ft.A - 3098 ft. I�
NC Well Contractor Certification Number ft. ft.
15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICKNESS MATERIAL
fr. fr. p in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft- 25.0 ft- 2.0 i 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 25.0"' 30.0 f` 2.0 in' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in:
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 15.0 ft' PORTLANDBENTONITE SLURRY
❑Monitoring ❑Recovery ft. fr.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 22.0 ft- 30.0 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) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft. 1.0 ft. ASPHALT/GRAVEL
4.Date Well(s)Completed: 10/25/21 Well ID# AS-1 1.0 ft. 5.0 ft- BROWN CLAYEY SILT
5a.Well Location: 5.0 f" 10.0 f`' GRAY/BROWN CLAYEY SILT
BEST PRICE CLEANERS 10.0 ft- 30.0 ft. BROWN CLAYEY SILT
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. i y
6820 DAVIS CIRCLE RALEIGH 27613 ft. ft.
Physical Address,City,and Zip ft. ft.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL�r.15.0--22.0 FEET`
***AIR SPARGE***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 51' 51.53" N 780 42' 39.26" W 10/29/21
6.Is(are)the well(s)' I!flPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I15No I5A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill out knonm well construction information and explain the nature of the of this record has been provided to the Lrell oumer.
repair under 921 remarks section or on the back ofilus 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-I 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: 30.0 (ft)
For multiple ire/Is list al/depths/fdi/ferent(example-3@200'and 2@I00') 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 easing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Iflvater level is above casing,use"+"
11.Borehole diameter: 8.0 (in,) 24b. For Infection Wells: Copy toIDWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER 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 1ve'i 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018