GW1-2022-05222_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
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. in.
Company Name
16.INNER CASING OR TUBING eothermal closed 7o6
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) 0.0 ft. 20.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: n.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 ft' 30.0 ft' 2.0 'n' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation []Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENr METHOD&AMOUNT
Non-Water Supply Well: 0.0 rt. 4.0 ft' PORTLANDBENTOWE SLURRY
INMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
El Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVET's`PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 18.0 "' 30.0 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,soiltmck type,grain size,etc.
0.0 ft. 5.0 ft. RED/ORANGE CLAY
4.Date Well(s)Completed: 04/08/22 Wel1ID# TW-1 5.0 ft. 17.0 ft. GRAY SILTY CLAY
5a.Well Location: 17.0 ft' 28.0 ft' BROWN SILTY CLAY
GLEN CANNON GOLF COURSE 28.0 ft- 30.0 ft. BROWN PWR
Facility/Owner Name Facility 1D#(if applicable)
ft. ft.
2422 WILSON ROAD PISGAH FOREST 28768 ft. ft.
Physical Address,City,and Zip
rt. ft.
TRANSYLVANIA 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-4.0-18.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
350 14' 13.43" N 820 41' 54.19" W 04/25/22
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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 ofthis record has beenprovided to the well owner. J t;Y� R ' ##"1
repair under#21 remarks section or on the back ofthis form. G-C"r E r V E-i-•1'
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 additio IAvrll fOrL tru4�p�L j�r�Lfo
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovet in Remarks Box).You may also attach a itional ages ifhecdssary.
drilled: 24.SUBMITTAL INSTRUCTIONS lnforiraa::,:n PrCcnzvtmtg Uni:
0
9.Total well depth below land surface: 30. ft D A'O/6OG
( .) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierem(example-3 a�1 00'and 2@100)
10.Static water level below top of casing: 10.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
/fu•ater level is above casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b.For Iniection 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