GW1-2022-07683_Well Construction - GW1_20220818

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR Ia.WATERzoriEs.-
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 3098 r ft. ft.
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NC Well Contractor Certification Number � - t..s y, •- 15.,OUTER;CASING,for tnu1H-ct d 'ells OR7:INER'if a' licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICK%S MATERIAL
n L n ft. ft. I in
Company Name J
,� t6:INNER CASING'OR.T,UBINC, ''eothermaldosed=too -=:
2.Well Construction Permit# +'�1?� ^�= +"�'�g UnW FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits t.e.UIC.CoOVJaiz ante,etc.) 0.0 ft. 5.0 ft• 2.0 1O I SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
7.Water Supply Well: 51FR M REENTO -` DIAMETER I` SLOT SIZE THICtQVFSS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 It 15.0 It. 2.0 in. .020 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It- 4.0 ft PORTLANDBENTONUE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge IDGroundwater Remediation
19.SAND/GRAVEUPACK ifa"'lieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.5 ft- 15.0 ft 20-46 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG Ottach4dditimiklsheets:if neeessa
FROM I TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft. 1.0 It. BLACK TOPSOIL
4.Date Well(s)Completed: 06/08/22 Well ID# IW-6 1.0 ft- 13.0 ft BROWN/RED SILTY CLAY
5a.Well Location: 13.0 ft- 15.0 ft• WHITE/GRAY SANDSTONE
WEAVER CLEANERS a' ft.
Facility/Owner Name Facility ID#(if applicable) ft. }
1209 DAWKINS STREET DURHAM 27707 ft. fL
Physical Address,City,and Zip ft. ft
DURHAM -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:
(if well field,one[at/long is sufficient) 22.Certification-
350 58' 55.82" N 780 53' 58.50" W 06/22/22
6.Is(are)the well(s): 15Permanent 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.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this 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: 15.0 (ft)
For 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:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 6'0 (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
10.0/6.0 24b.For Injection Wells:Copy t 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 departTnent of the county where insta led
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
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13b.Disinfection type: Amount: f
Environmental Quality-Division of Water Resources i Revised 6 6-2018
Form GW-1 North Carolina Department of E Q ty
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