GW1-2022-05174_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 1a.WATER ZONES,
Well Contractor Name FROM TO DESCRIPTION
..a.�
A - 3098 �", � r I� -I, ft. ft.
1 g Lh2L n q i
NC Well Contractor Certification Number ft. ft.
MAY 3 d ,15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name Irommi`3$jEil rj}t;,yo 0 ft. ft is
D%-VQ/'ap(3 '46.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits#.e.UIC,County,State,Variance,etc.) 0.0 ft. 23.0 ft, 2.0 SCH 40 PVC
3.Well Use(check well use): ft. It. in.
17.'SCREEN.•,,
Water supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 23.0 ft. 33.0 fL 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f, ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑IITI ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It. 19.0 ft. PORTLAND aENTONITE SLURRY
[EMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
a19.SAND/GRAVEL'PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 21.0 ft 33.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardn soillrvcktype rain size,etc.
0.0 ft. 4.0 ft. RED CLAY
4.Date Well(s)Completed: 04/28/22 Well ID# PZ-A 4.0 ft. 33.0 ft BROWN SILTY CLAY
Sa.Well Location:
ft. ft.
SOUTH WAKE LANDFILL ft. ft.
Facility/Owner Name.. Facility ID#(if applicable) ft. ft.
6330 OLD SMITHFIELD ROAD APEX 27539 ft. ft.
Physical Address,City,and Zip ft. ft.
WAKE ''21.REMARKS:, = _ .,
County Parcel Identification No.(PIN) BENTONITE SEAL-19.0-21.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35e 40' 53.11" N 780 50' 41.08" W �j u tti 05/19/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(1vere)constructed in accordance Ivith
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 copy
If this is a repair,fill out known ivell construction information and explain the nature of the of this record has been provided to the ivell owner.
repair under#21 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: 33.0 (ft)
For multiple wells list all depths ifeli 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: 25.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifivater level is above casing,use'•+„ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0/4.0 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018