GW1-2022-05220_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. j
A - 3098 ft. ft j
NC Well Contractor Certification Number 15w OUTER CASING for multi-caied wells OR LINER;if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft, ft. is
Company Name
'16.INNER CASING OR TUBING eothermal closed-hm
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County.State,Variance,etc) 0.0 ft. 12.0 ft. 2.0 in, SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN .' o
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 12.0 f" 22.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) is.GROUT'
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 4.0 ft' PORTLANDaENTONITE SLURRY
INMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL"PAC K if applicable),
_ *• .F
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 10.0 ft. 22.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets if necessary),
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIMON color,hardness,soil/rock type,grain size,etc.
0.0 ft. 6.0 ft. RED CLAY
4.Date Well(s)Completed: 04/08/22 Well ID# TW-3 6.0 fl' 12.0 It. BROWN CLAY
5a.Well Location: 12.0 ft' 22.0 ft' BROWN PWR
GLEN CANNON GOLF COURSE ft. ft.
Facility/Owner Name Facility lD#(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)
BENTONIfE SEAL-4.0-10.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 14' 13.43" N 820 41' 54.19" W 4 04/25/22
6.Is(are)the well(s): 19Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the rvell(s) (r' )Jco�nr ct�ip_� nc with
7.Is this a repair to an existing well: ❑Yes or MNo !SA NCAC 02C.0100 or ISA NCAC 02C.0200 We!G�t}sttu tefr rt r a r; a copy
If this is a repair,fill out known Tvell construction information and explain the nature of the ofthis record has been provided to the well oivner.
repair under#21 remarks section or on the back of this form. MAY 3 12022
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobr/DPT or Closed-Loop Geothermal Wells having the same �•
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You mayC3138t9tta'd�� rary.
drilled: 24.SUBMITTAL INSTRUCTIONS DkIMMOG
9.Total well depth below land surface: 22.0 (ft.)
For multiple wells list all depths ifdierent(example-3@200'and 2@I00) 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),
If
f water level is above casing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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(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