GW1-2022-08509_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098
NC Well Contractor Certification Number E 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXP LO RATIO N +�.. FROM TO DIAMETER THICIINFSS MATERIAL
ft. ft. in
Company Name
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: P .f;zerz0'g UrA FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(1. ou ce,etc.) 0.0 ft. 10.0 ft. 6.0 1O SCH 40 PVC
3.Well Use(check well use): 1177�� ft• ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft• 50.0 ft' 6.0 in. .010 SCH 40 PVC
El Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 6.0 ft' PORTLANDBENTONITE SLURRY
❑Monitoring IERecovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL`PAC K if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 8.0 ft. 50.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary),
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
0.0 ft. 10.0 ft. RED/ORANGE CLAY
4.Date Well(s)Completed: 04/14/22 Well ID# RW-8 10.0 ft. 18.0 It. BROWN SANDY SILTY CLAY
5a.Well Location: 18.0 ft. 50.0 ft' WHITE/BROWN SANDSTONE
SEABOARD CHEMICAL ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5899 RIVERDALE DRIVE JAMESTOWN 27282 ft. ft.
Physical Address,City,and Zip ft. ft.
GUILFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-6.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35e 56' 49.67" N 79e 54' 38.22" W 04/18/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certijy 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 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe ofthis 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 Ove?in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 50.0 (ft.)
For multiple wells list all depths ifdJjerent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the fallowing:
10.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
Iftvater level is above casing,use"+"
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
12.0/7.875 24b.For Injection Wells:Copy to 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 department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018