GW1-2022-07687_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR ,14.WATER ZONES .
FROM TO DESCRH'TION
Well Contractor Name ft. ft. 1
A - 3098 ft. ft.
NC Well Contractor Certification Number 15.'OUTEWCASING for molt*-casedwells ORtLINER.ifa licable
y k y 1 k FROM TO DIAMETER THICKNESS MATERIAL
GEOLOGIC EXPLORATION a v9 777..,a
ft. ft. I 'in.
Company Name 7 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#:
P y AIJr ! "ch /^`022 FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e. Unit
UIC C un S are Va(ante{erf1 0.0 ft• 5.0 ft- 2.0 1O SCH 40 PVC
Ir1��. t`�i;►��h r"�r,�,,c3,a^�
3.Well Use(check well use): D%A1Q130G ft. ft. in.
=
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL-
0 Agricultural ❑MunicipaVPublic 5.0 "' 15.0 it" 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:
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 4.0 ft' PORTLAND BENTONIT E SLURRY
❑Monitoring ❑Recovery fr. ft.
Injection Well: ft. ft.
❑Aquifer Recharge 15Groundwater Remediation
19.SAND/GRAVEIiPACK(if a Mable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.5 rt- 15.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer iO.'DRILLING LOG'ittich'additioiral sheets ifneeessa'
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn soil/rock type,grain size etc.
0.0 It. 1.0 It. BLACK TOPSOIL
4.Date Well(s)Completed: 06/10/22 Well ID# IW-10 1.0 ft. 60 n- RED/ORANGE CLAY
5a.Well Location: 6.0 rl' 12.0 fL BROWN MUDSTONE
WEAVER CLEANERS 12.0 ft 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 RH AM z1sREMARK&�'"
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 latAong is sufficient) 22.Certification-
35° 58' 55.82" N 78° 53' S8.50" W 06/22/22
6.Is(are)the well(s): OPermanent 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 ONo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe ofihis 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-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:
6.0 24a. For All Wells: Original f6rm to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: 10.0/6.0 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,N&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 depaitrnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducm`over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Ralei ,NC 27699-1611
13a.Yield(gpm) Method of test:
i
13b.Disinfection type: Amount:
f
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2019