GW1-2022-07677_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 DESCRIPTIONft. ft.
A - 3098
z a /'•" ft. ft.
NC Well Contractor Certification Number ' C y �t E y % 15 OUTER CASING formidh cased!wells ORZINER;ita licable
._
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. fL is
Company Name
Y 16.1NNER CASING,OR-- UBING edthermal closed-lob
2.Well Construction Permit#: t PAC^ ?fc}"iRJ UrUl FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UI ounty,Statte< �i pR g k.) 0.0 It- 5.0fL 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN,. ?
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft. 15.0 ff 2.0 ER .020 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 78.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 4.0 ft' PORTLAND BENTONRE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft
❑Aquifer Recharge OGroundwater Remediation
19.'SAND/GRAVEL'PACI{(if a Gcab
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO f MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 4.5 ft. 15.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.'DRIL'LING10 as tith`additioiiiiiUsheets iTriecissi
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn soil/rock type,grain Sim,etc.
0.0 ft. 1.0 ft. BLACK TOPSOIL
4.Date Well(s)Completed: 06/10/22 Well ID# IW-14 1.0 ft. 5.0 ft- RED/ORANGE CLAY
5a.Well Location: 5.0 ft. 15.0 ft. WHITE SANDSTONE
WEAVER CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
DAWKINS STREET R.O.W. DURHAM 27707 ft. ft.
Physical Address,City,and Zip
ft. ft.
DU RHAM 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-4.0-4.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
350 58' 55.48" N 780 53' 59.35" W ' ` 06/22/22
6.Is(are)the well(s): 091"ermanent 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 1!9No ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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#11 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: 15.0 (ft.)
For multiple wells list all depths ifeli ferem(example-3(200'and 2Q100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 6.0 (it) 24a. For All Wells: Original foim 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: 10.0/6.0 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
AUGER/AIR Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and OpenLoop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin ±over 100 000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Ralel ,"NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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