GW1-2022-07688_Well Construction - GW1_20220818

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14 WATER,ZOlYRS.'
FROM TO DESCRIPTION
Well Contractor Name ft. ft. j
A - 3098 _ {{ rt. ft '
NC Well Contractor Certification Number i '��,. �5,' i Rf .- h.rr 15 OUTER CASING for rh cased wells OR,LINER if-a able)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICINIESS MATERIAL
IV1 1 1 �V ft. ft. is
Company Name 16;INNER:C kSING:OR TUBING eothermal closed-loo
2.Well Construction Permit#: IfIECiFf 1 l�' ` UR11 FROM TO DIAMETER THICIQVESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,5'(alp'a6Cai,'ia c Ic.) 0,0 ft' 55.0 ft. 2.0 In- SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Sul SCREEN
PP Y Well: FR FROM TO DIAMETER SLOT SIZE THICINIESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 "' 15.0 ft' 2.0 In' .020 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• g, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT
❑bTi ation ❑Wells>100000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 4.0 ft- PORTIANDBENTONUE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVELPACIC if amilicable"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTME IIOD
❑Aquifer Test ❑StormwaterDrainage 4.5 ft- 15.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology 'Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING.LOG atfachadditioual'ahects'ifnecessa'
FROM I TO DESCRIPTION color,hardness,soiUrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0.0 ft. 0.5 IL ASPHALT
4.Date Well(s)Completed: 06/08/22 well ID# IW-12 0.5 rl. 1.0 rt. GRAVEL
5a.Well Location: 1.0 ft. 6.0 ft' ORANGE CLAY
WEAVER CLEANERS 6.0 fl. 15.0 ft- BROWN CLAY
Facility/Owner Name Facility ID#(if applicable) ft. ft.
DAWKINS STREET R.O.W. DURHAM 27707 ft. M
Physical Address,City,and Zip ft. ft.
DURHAM 21.REMARKS!,�' <. .
County Parcel Identification No.(PIN) BENTONIfE 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' 55.48" N 78° 53' S9.35" W �` 06/22/22
Signature of Certified Well Contractor,
6.Is(are)the well(s): OPermanent or ❑Temporary
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 09No 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 rhelwell 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 ifdii ferem(example-3(Qa 200'and 2Q100) 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 (in.) 24b.For Injection Wells:Copy;'to DWR,Underground Injection Control(WC)
11.Borehole diameter: Program,1636 MSC,Raleigh,NCh 27699-1636
12.Well construction method: AUGER/AIR 24c.For Water Su 1 and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health epa l rtment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinit over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.field(gpm) Method of test:
13b.Disinfection type: Amount:
R
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018