GW1-2022-07680_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
JOHNNY BURR 14.WATER.ZONES`
_ FROM TO DESCRIPTION
Well Contractor Name 4 P
A - 3098 ''�E } VE Cj ft. ft
c fr. ft. �
NC Well Contractor Certification Number A U r "IS 2022 15..OUTER'CASING(for`multi-cased wells OR LINER ifa `licable
GEOLOGIC EXPLORATION FROM TO DIAMETER TxICKNg MATERIAL
x;rr a :,..,:.r.,,..,•.
u ft. ft.
t is
Company Namc
1C INNER.CASING OR TUBING' edthekmal'clos`ed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 5.0 ft- 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 IL 15.0 ft. 2.0 in.
.020 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) ;IgGROUT
❑1rR ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 4.0 IL PORTLANDBENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge 15Groundwater Remediation
19.'SAND/GRAVEL PACKQfiiiipliciblel
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 4.5 fr- 15.0 fL 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer "20s.DRILLING'IiOG "a'ffii' ditioeal7sheets:if.'riecessa „q.',
❑Geothermal(Heating/Cooling Return) ❑Other(e PTI
lain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soi0rock type,train size etc.
0.0 II• 1.0 ft. BROWN/BLACK TOPSOIL
4.Date Well(s)Completed: 06/08/22 Well ID# IW"3 1.0 ft- 14.0 fL BROWN/RED SILTY CLAY
5a.Well Location: 14.0 ft• 15.0 "' i WHITE/GRAY SANDSTONE
WEAVER CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1205 DAWKINS STREET DURHAM 27707 ft. ft.
Physical Address,City,and Zip ft. ft.
DURHAM z1.REMARKS'
County Parcel Identification No.(PIN) BENTONITE SEAL-4.0-4.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 58' 56.35" N _ 780 53' 58.36" W '644e1 06/22/22
6.Is(are)the well(s): 091'ermanent or ❑Temporary Signature ofCerfified 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 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 I 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.)
For multiple wells list all depths ifdfferent(example-3(200'and 2 a@100q Submit this GW-1 within 30 days of well completion per the following:
6.0 249. For All Wells: Original form to Division of Water Resources (DWR),
]0.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
11.Borehole diameter: 1 0.0/6.0 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
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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:
4
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018