GW1-2022-05829_Well Construction - GW1_20220609

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: k
1.Well Contractor Information: II
JOHNNY BURR 14.WATER ZONES .
Well Contractor Name FROM TO DESCRIPTION
A - 3098
ft. I ,
ft, ft. L.
NC Well Contractor Certification Number 75.OUTER CASING for multi=cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER! THICKNESS MATERIAL
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Company Name
16.INNER CASING OR TUBING eothermat closed-loo
2.Well Construction Permit#: FROM TO I DIAMETER f THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.111C,County,State,Variance,etc.) 0.0 ft. 13.0 ft- 2.0 �i sn• SCH 40 PVC
3.Well Use(check well use): ft- It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER.' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 13.0 "- 28.0 It- 2.0 in• .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.i
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 5.0 It' PORTLAND BENTONITE SLURRY
29Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ira licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 10.0 ft 28.0 fit- 20-40', FINE SIUCA 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 soil/rock type,grain sire,etc.
0.0 rt• 3.0 rt• RED/ORANGE CLAY
4.Date Well(s)Completed: 05/18/22 Wel11D# SSLF-PZ-2 3.0 rt. 28.0 ft. BROWN SANDY CLAY
5a.Well Location: ft. ft.
ALLEN STEAM STATION ; OP
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
253 PLANT ALLEN ROAD BELMONT 28012 ft. rt. JUN 01.,2022
Physical Address,City,and Zip ft. ft.
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GASTON 21.REMARKS -
County Parcel Identification No.(PIN) BENTONrrE SEAL-5.0-10.0 r4l
***PIEZOMETER***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: n,
350 11' 17.03" N 81° 00' 40.51" w 05/23/22
6.ls(are)the well(s): (EPermanent or ❑Temporary Signature of Certified Well Contractor ; Date
By signing this form,1 hereby certt&that the svell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IDNo 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under i'21 remarks section or on the back of this farm.
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-l is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You ritay also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 28.0 (ft.)
For multiple we/Is list all deplits ifdii#ereni(example-3@200'and 2 n 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 Ito Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: 8.0 (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER I '
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departmenit 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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