GW1-2022-05121_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR s14 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 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 I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) 0.0 ft. 40.0 ft. 2.0 1° SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FR REE
MTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 40.0 ff 60.0 ft' 2.0 in' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL_ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 36.0 ft- PORTLANDBENTONRE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge El Groundwater Remediation
19:SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 38.0 ft- 60.0 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#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type rain size,etc.
0.0 ft. 5.0 ft. BROWN SILTY CLAY
4.Date Well(s)Completed: 04/22/22 Well ID# PZ-6-3 5.0 ft. 48.0 ft- BROWN/TAN SILT
5a.Well Location: 48.0 ft' 60.0 ft' GRAY ROCK
WILKES COUNTY LANDFILL ft. ft.
Facility/Owner Name Facility ID#(it'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) BENTONIfE SEAL-36.0-38.0 FEET
***PIEZOMETER***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlong is sufficient) 22.Certification:
360 12' 27.47" N 800 59' 24.00" W ?-&-r/ 04/28/22
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were).0,zlin @QL a ivith
7.[s this a repair to an existing well ❑Yes or �No /SA NCAC 02C.0/00 or/SA NCAC 02C.0200 W dR�u Wait af`d iad t t copy
If this is a repair,fill out known ivell construction information and explain the nature of the ojthis record has been provided to the well owner. `? I--
repair under#21 remarks section or on the back of this form. h
23.Site diagram or additional well details: H� YOna we� � �
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide a t c suction info
construction,only1 GW-1 is needed. Indicate TOTAL NUMBER ofwells (add'See Over in Remarks Box).You may also attach addii onal�";, if_n jRWary.
3At S
drilled: If1�OfFfrAuW s: f``""' '`
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 60.0 (ft.)
/%or multiple we//s list all depths ifdii ferent(example-3(a 200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
37.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft.) Inforation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" m
C.0 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR
24c.For Water Supp1Y 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 GPI: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