GW1-2022-05828_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
JOHNNY BURR 14:WATER ZONES r '
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098
ft. ft. I
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. k in.
Company Name l
16.INNER CASING OR TUBING eothermal closed-loon)'
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable ivel/construction permits(i.e.VAC,County,State,Variance,etc.) 0.0 ft. 19.0 ft. 2.0 iO' SCH 40 PVC
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER! SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 19.0 ft' 29.0 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) 18:GROUT
Z.
❑Irrl ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 12.0 ft' PORTLAND BENTONITE SLURRY
INMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicablel- -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 17.0 ft. 29.0 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,soiUrock type,gmin size,etc.
0.0 ft. 6.0 ft- RED CLAY
4.Date Well(s)Completed: 05/19/22 well ID# SS LF-PZ-3 6 0 tt. 18.0 ft BROWN SANDY CLAY
5a.Well Location: 18.0 tt. 29.0 ff BROWN SANDY SILTY CLAY
ALLEN STEAM STATION rt. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
253 PLANT ALLEN ROAD BELMONT 28012 rt. ft.
Physical Address,City,and Zip
GASTON 21.REMARKSinfew"an PFfLft
County Parcel Identification No.(PIN) BENTONITE SEAL- 12.0-17.0 FEET DlYlZ.�
�:7
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***PIEZOMETER***
(if well field,one]at/long is sufficient) 22.Certification:
350 11' 16.01" N 81° 00' 38.91" W "� 05/23/22
6.Is(are)the well(s): (EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this•form,1 hereby certify that thi tvell(s)was(were)constructed in accordance a ah
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
/f this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 421 remarks section or on the back oflhis 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 I GW-I 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: 29.0 (ft.)
For multiple ive/1r list all depths ifdtfferent(example-3@200'and 1 rt 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
(jwater lorel is above casing,use"i" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I
11.Borehole diameter: 8.0 (in) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.1Ye11 construction method: AUGER '
24c.For Water Supply and Open-LoopI 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 27699-1 61 1
13b.Disinfection type: Amount:
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018