GW1-2022-07690_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: l
JOHNNY BURR 14:wATERZONEs;
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098 '+ E 9 V aZ.D ft. ft.
NC Well Contractor Certification Number (� ,15 OUTER CASING'fdrlmulti-cased'Wells OR T INER ita livable
GEOLOGIC EXPLORATION F'.I�� Z � FROM I To DIAMETER THICIWISS MATERIAL
ft. ft. in.
Company Name _X_zG St 4J a ft
16.INNER CASING-OR BING eothermal closed-loop),
2.Well Construction Permit#: +� b FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 rt. 5.0 IL 2.01 in. SCH 40 PVC
3.Well Use(check well use): ft. fa in.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 "' 15.0 rt' 2.0 'n' .020 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18._GROUT
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 4.0 rt' PORTtAND BENTONRE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEIr PACK`if a 0ti able
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
❑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-DRILLING'LOO'attiicii dditionalasheets�if;oeceis'a
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 it. 0.5 ft. ASPHALT
4.Date Well(s)Completed: 06/08/22 Well ID# IW-13 0.5 ft. 1.0 rt• GRAVEL
5a.Well Location: 1.0 ft. 6.0 ft' RED/ORANGE CLAY
WEAVER CLEANERS 6.0 ft- 15.0 ft. . BROWN CLAY
Facility/Owner Name Facility ID#(if applicable) ft. ft. it
DAWKINS STREET R.O.W. DURHAM 27707 ft. ft.
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:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 58' 55.48" N 780 53' 59.35" W ?7_7/ '�'� 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 ONo 15A NCAC 01C.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 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 iftifferent(example-3@200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 6.0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
/f water level is above casing,use"+^ Information Processing Unit,1617 IMSC,Raleigh,NC 27699-1617
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 Opeu f-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 /
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
j
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourcest Revised 6-6-2018