GW1-2022-07678_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
tt. ft. r
A - 3098 _ ft. ft.NC Well Contractor Certification Number (^� 9��ft :
GEOLOGIC EXPLORATION 15:OUTERCASING formulti-caseilwells OR LINER ifa licable
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name p U G ! _
16.INNER CASING OR TUBING. eothermal closed-loo
2.Well Construction Permit#: I Inh FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC, iS7dh aNidd a (c.) 0.0 ft- 5.0 ft. 2.0 1n. $CH 40 PVC'
rj+f3:2t�C�
3.Well Use(check well use): ft. ft. in.
Water Supply Well: $7:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaYPublic 5.0 fL 15.0 fL 2.0 1n' .020 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
01rrl ation ❑Wells>100000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 4.0 ft' PORTLANDBENTONUE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge 15Groundwater Remediation
19.SAND/GRAVEL PACK if.a""lii'.ible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.5 ft. 15.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control tt. ft.
❑Geothermal(Closed Loop) ❑Tracer d0.DRILLING LOG attach additional sheets if necessii
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn soiltrock type,grain size etc.
0.0 ft. 1.0 It. BROWN/BLACK TOPSOIL
4.Date Well(s)Completed: 06/06/22 Well ID# IW-1 1.0 ft. 13.0 ft• BROWN/RED SILTY CLAY
5a.Well Location: 13.0 ft. 15.0 It' WHITE/GRAY SANDSTONE
WEAVER CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. I
1205 DAWKINS STREET DURHAM 27707 ft. ft.
Physical Address,City,and Zip
ft. ft.
DURHAM
County Parcel Identification No.(PIN) BENTONIfE SEAL-4.0-4.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 58' 56.35" N 780 53' 58.36" W 06/22/22
6.Is(are)the well(s): INPermanent 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 I!9No ISA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the afthis record has been provided to the well owner.
repair under 421 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-I 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.
Eor multiple wells list all depths ifdifferent(example-3@200'and 2@100) ) Submit this GW-1 within 30 days of well completion per the following:
6.0 (it) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
ifwater level is above casing,use"+' Information Processing Unit,1617 fMSC,Raleigh,NC 27699-1617
0,0/6,0 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter. (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/AIR
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