GW1-2022-07651_Well Construction - GW1_20220818

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 I +. C E o �i ® fr. ft. k
NC Well Contractor Certification Number �+ 15.<OUTER CASING(for inu1H-cased>wells OR LINER'if e" 'licatile '
GEOLOGIC EXPLORATION p��(; S 2�22 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
t F�UM F.16:INNER CASING OR"TUBING eofherinil`cld'sed466 ='
2.Well Construction Permit#: Iflfris{ r' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.t ,Cotrhfy,`tote,Variance,etc.) 0.0 ft. I0.0 fL 2.0' 1n' I SCH 40 PVC
3.Well Use(check well use): % ft. in.
Water Supply Well: 17.SCREEN,
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 f" 40.0 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) r18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 5.0 ft' PORTtANOBENTONRE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK"if a 'liceblc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 8.0 rt- 40.0 IL 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer20fDRILLING;LOG attacti-iidditiouih`s`heetsifiiecessa °iY, .,, .,'`_
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnM soRtrock bW,grain size,etc.
0.0 ft• 1.0 ft. GRAVEL/TOPSOIL
4.Date We11(s)Completed: 07/13/22 well ID# MW-12 1.0 ft- 40.0 it• BROWN/GRAY PWR
Sa.Well Location:
ft. ft.
NCDOT MAINTENANCE YARD ft. ft.
i
Facility/Owner Name Facility 1D#(ifopplieable) ft. ft. p
5426 NC - 141 MARBLE 28905 ft. ft.
Physical Address,City,and Zip ft. ft
CHEROKEE 21.REMARKS,'• ;'
County Parcel Identification No.(PIN) BENTONIfE SEAL-5.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 08' 17.81" N 830 55' 31.71" W d" er 07/29/22
6.Is(are)the well(s): 191'ermanent or ❑Temporary Signature ofCertified 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 19110 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/fthis 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#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 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: 40.0 (ft)
For multiple wells list all depths ifdifferent(example-3@200'and 2@/00') ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 25.0 (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: 6.0 (in.) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR 24c.For Water Supply and Open i 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 producin2!over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 611
13b.Disinfection type: Amount:
Form OW-I North Carolina Department ofEnvironinental Quality-Division of Water Resources Revised 6-6-2018