GW1-2022-08708_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.,WATEWZONEs . w.;;,.
Well Contractor Name FROM TO I DESCRIPTION
ft. ft. 1
A - 3098 ft. ft.
NC Well Contractor Certification Number "15.�OUTER CASING.for.,rnulti-casedi-as:ORI$NER ifi licable �. �•"'. ."
GEOLOGIC EXPLORATION FROM TO DIAMETER r THICKNESS MATERIAL
ft. ft. in.
Company Name ^
"16`3NNER CASING OR;TUBING eothermal closed-loo ''
2.Well Construction Permit#: FROM To DIAMETER I THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) 0,0 ft. 19.0 It. 2.0 'n' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
"17.SCREEN �: r
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL. -
❑Agricultural ❑Municipal/Public 19.0 ft' 29.0 fi' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18::GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fi- 13.0 ft' PORTMDBENTONTTE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater•Remediation
19.°SANDlGRAYEG PACK if a licrbli,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 17.0 ft- 29.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 211 DRILLING%O'G attach additional sheets ifnecessii
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillmck type,gmin size,etc.
0.0 fc 3.0 ft- RED/ORANGE CLAY
4.Date Well(s)Completed: 05/04/22 Well ID# PZ-A 3.0 ft- 15.0 ft. BROWN PWR
5a.Well Location: 15.0 ft' 29.0 ft' GRAY ROCK
DAVIDSON COUNTY LANDFILL ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1242 OLD US HIGHWAY 29 THOMASVILLE 27360 ft. ft.
Physical Address,City,and Zip
ft. ft.
DAVIDSON 21:REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-13.0-17.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
350 51' 11.62" N 800 10' 34.66" W k""� 05/19/22
6.Is(are)the well(s): TPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the ivell(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 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 of the ofthis record has been provided to the Tvell owner.
repair under#21 remarks section or on the back of this form. ®J
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 adddit'ongll page ff liecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS ����3�
9.Total well depth below land surface: 29.0 (ft.)
For multiple ivel/s list all depths ifdierent(example-3 rJ 00'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 18.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifivater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 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: 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 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018