GW1-2022-07418_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR �14:=wATERZONRs ,. :
Well Contractor Name FROM TO SDESCRIPTION
ft. ft.
A - 3098 a�� ft. ft. �
NC Well Contractor Certification Number 15:OUTER"CASING for-midti-cased'4tlis'OR LINER if:a licable
GEOLOGIC EXPLORATION q qq FROM TO DIAMETER THICKNESS MATERIAL
b�6� ft. ft. in ,
Company Name
16.INNER CASING OR TUBING' 6thermal'closed Ioo`
2.Well Construction Permit#: pro`ti ^'t"0 Urv� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits#.e.UIC, , iate,v .j 0.0 ft. 5.0 ft. 2.0 1° SCH 40 PVC
3.Well Use(check well use): ft. & in.
Water Supply Well: A7.SCREEN,"
FROM TO DIAMETER SLOT SIZE THICKNESS 'MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft' 15.0 ft. 2.0 1 L .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.'.ROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 n- 3.0 ft' PORTLANDBENTONrrE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
"-PACK if applicable SAND/GRAVEL,
❑Aquifer Storage and Recovery ❑Salim ty Barrier FROM TO
MATERIAL EMPLACEMENTMETHOD
[]Aquifer Test ❑Stormwater Drainage 4.0 ft. 15.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLINGaLOG°attacti aadiHo°alsbeets'ifuecessa° '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrocktype rain size,etc.
0.0 ft. 1.0 ft. GRAVEL
4.Date Well(s)Completed: 05/11/22 Well ID# MW-1 1.0 ft. 8.0 ft. GRAY SANDY CLAY
5a.Well Location: 8.0 ft. 15.0 ft' RED/ORANGE SAND
CHAPEL HILL TIRE CO-MPANY ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
203 WEST MAIN STREET CARRBORO 27510 ft. ft.
Physical Address,City,and Zip ft. ft
ORANGE 21.REMARK&«,
County Parcel Identification No.(PIN) BENTONIfE SEAL-3.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 54' 36.37" N 790 04' 32.73" � 05/26/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has beenprovided to the well owner.
repair under#21 remarks section or on the back ofthis 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 1 GW-1 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: 15.0 (ft)
For multiple wells list all depths ifdifferent(example-3 a200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easing: 10.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use•'+" 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(NC)
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