GW1-2022-05219_Well Construction - GW1_20220531

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.
A - 3098 rt. ft.
NC Well Contractor Certification Number
'I5OUTER CASING for multi-cased wells OR LWER.if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKINESS MATERIAL"
' ft. ft. is
Company Name
16.INNER CASING OR.TUBING'(geothermal closed-loop),
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 7.0 ft. 2.0 in• SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 7.0 ft. 17.0 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) is.GROUT
❑Irrl ation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 ft' PORTLANDBENTONITE SLURRY
Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
'19:SAND/GRAVEL PACK if a'"licable "
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 5.0 ft. 17.0 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 TO DESCRIPTION color,hardness,soil/ruck type,grain size,etc.
0.0 ft. 3.0 ft. RED/ORANGE CLAY
4.Date Well(s)Completed: 04/07/22 Well ID# TW-2 3.0 ft. 8.0 ft. TAN CLAY
5a.Well Location: 8.0 ft' 15.0 ft' TAN SANDY CLAY'
GLEN CANNON GOLF COURSE 15.0 ft. 17.0 ft. BROWN PWR
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
2422 WILSON ROAD PISGAH FOREST 28768 ft. ft.
Physical Address,City,and Zip
ft. ft.
TRANSYLVANIA 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-5.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certification:
35e 14' 13.43" N 82e 41' 54.19" W 04/25/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing lhis form,l hereby certify tha!the well( ks'(we $t t 6�"" a with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 G�snsr o �lasid, d rand Pbar a copy
If this is a repair,fill out known ivell construction information and explain the nature of the oflhis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. MAY 3 1 2022
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 mao'Mi M'P URFI Ma#ssary.
drilled: O°,C�iM
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 17.0 (ft.)
For multiple ivells list all depths ifdti feren!(example-3@200'and 2Q100� Submit this GW-1 within 30 days of well completion per the following:
10.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
/fi f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
valer level is above casing,use"+"
11.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-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(gP m) 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