GW1-2022-05116_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 3098 ft. ft.
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. is
Company Name 16,INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMEFER THICKNESS. I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Irariance,etc.) 0.0 ft. 65.0 ft. 2.0 1°' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.,SCREEN
Water Supply Well
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 65.0 It" 125.0 ft' 2.0 1°' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT MFrHOD&AMOUNT
Non-Water Supply Well: 0.0 ft, 61.0 ft- PORTLAND aENTONrTE SLURRY
❑Monitoring ❑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 EMPLACEIIIENT METHOD
❑Aquifer Test ❑StormwaterDrainage 63.0 ft. 125.0 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) inOther(explain Linder#21 Remarks) FROM I TO DESCRIPTION color,hardness,sail/nick type,grain sin,etc.
0.0 ft• 5.0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 04/22/22 Well ID# PZ-6-1 5.0 ft• 38.0 ft. BROWN/TAN SILT
Sa.Well Location: 38.0 ft. 125.0 "' GRAY ROCK
WILKES COUNTY LANDFILL ft. ft.
Facility/Owner Name Facility ID#(if applicable) _ ft. ft.
9219 ELKIN HIGHWAY ROARING RIVER 28669 ft. ft.
Physical Address,City,and Zip ft. ft.
WILKES 21.REMARKS',
County Parcel Identification No.(PIN) BENTONITE SEAL-61.0-63.0 FEET
***PIEZOMETER***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
360 12' 27.47" N 800 59' 24.00" W 04/28 22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCertified Well Contractor "1p .�ei 1 r-0
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 [nNo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Co"'NIAbn Srnlarc M-11a1 a copy
If this is a repair,fill out known well constriction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form. ti 7
23.Site diagram or additional well details:)D#OfrS+iDl i t a'�=+rz�in9 Unh
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additio5A5*Qllatidstruction 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: 125.0 (ft.)
For multiple,yells list all depths ifdi ferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ff•)
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifrvater level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6'0 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR 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 over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-16]1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018