GW1-2022-07686_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 I DESCRIPTION
Well Contractor Name
ft. it.
A - 3098 p it• ft.
NC Well Contractor Certification Number 15.OUTER.CASING form idti4ased'.wetls OR;LUYER if a licable
GEOLOGIC EXPLORATION : .-�W��-' i FROM To DIAMETER THICKNESS MATERIAL
ft. ft. � in.
Company Name c' (�
16.INNER CASING OR";TUBING 'eotheimal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UI Woun 8tetq t]ih�irrx' .r 0.0 ft' 5.0 ft' 2.0 1°' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SC
Water Supply Well: FROM REENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 tL 15.0 ft' 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.
01tri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 4.0 ft' PORTLANDBENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge OGrormdwater Remediation
19.SAND/GRAYEL'PACK'ifs" Iica8le.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 4.5 ft- 15.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer `20.•DRILLING10G"i ttecti additiorisl sheets if iecessa""
FROM I TO DESCRIPTION
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks color,hardness soiUrock rain size,etc.0.0 ft. 1.0 f. BLACK TOPSOIL
4.Date Well(s)Completed: 06/10/22 Well ID# IW-9 1.0 ft. 5.0 f" RED/ORANGE CLAY
5a.Well Location: 5.0 ft' S.0 ft' BROWN MUDSTONE
WEAVER CLEANERS 8.0 fl• 15.0 ft- WHITE SANDSTONE
Facility/Owner Name Facility ID#(if applicable) ft. ft. f '
1209 DAWKINS STREET DURHAM 27707 ft. ft.
Physical Address,City,and Zip ft. ft.
D U R H A M 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 lat/long is sufficient) 22.Certification:
350 58' 55.82" N 780 53' 58.50" W ` 06/22/22
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature ofCertiSed 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 15A NCAC 02C.0100 or I5A 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 of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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-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 ifdierent(example-3@200'and 1@100) Submit this GW-1 within 30 days of well completion per the following:
6.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fG) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water 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
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 roducin over 100 000 GP Copy to DWR,CCPCUA
Permit Program,1611 MSC,Ralei ,NC 27699-16t 1
13s.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmentat Quality-Division of Water Resources Revised 6-6-2018