GW1-2022-07649_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR ,A4.WATERZONES1
Well Contractor Name FROM TO `DESCRIPTION
A - 3098 ft. ft.
ft. ft.
NC Well Contractor Certification Number F^ -t�' 4 4
yR"iN i 15.OUTER CASING.for,mulh cased"wells'OR,LINER'ifa°"°ficeble
GEOLOGIC EXPLORATION FROM TO DIAMETER THICIaIESS MATERIAL
ft. � ft � is,
Company Name �, t
,16.'INNER CASING OR,TUBING`i thei-mal closed-loo '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC, W r gg,d� 0.0 ft' 5v.0 fL 2'0 1O SCH 40 PVC '
�t:�ldlYS
3.Well Use(check well use): ft' f' in.
Water Supply Well: J7.-SCREEN..`,: ,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 fc 15.0 ft' 2.0 1O- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ,&_GROU h
❑Irri ation ❑Wells>100,000 GPD FROM TOf „MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:' 0.0 ft- 2.0 ft' PORTLAND BENTOWTE SLURRY
(Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
' 19.SAND/GRAYEL4Pi1GK(if a' fici6le „
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft' 15.0 fL 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer "20.DRILLING LOG attic 'skiditkinil sheets ifnecessa yz,,�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
0.0 ft. 1.0 ft GRAVEL
4.Date Well(s)Completed: 07/01/22 Well ID# OW-4 1.0 ft- 15.0 ft- BLACK SILTY SAND
5a.Well Location: ft. ft.
INTERNATIONAL PAPER ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1785 WEYERHAEUSER ROAD VANCEBORO 28586 ft' ft'
Physical Address,City,and Zip. ft. ft.
CRAVEN
County Parcel Identification No.(PIN) BENTONITE SEAL-2.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
350 12' 50.07" N 770 06' 59.67" W 07/18/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or INNo 15A 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 ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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 wel Is (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: 18'0 (ft.)
For multiple wells list all depths ifoli ferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 16.0 (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(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 roducin over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Ralet NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources;r Revised 6-6-2018
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