GW1-2022-08709_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR1a:�wATERzoNRs
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098 ft. ft.
NC Well Contractor Cerrtiification Number 1,15.OUTER CASING for mn1ti-casedIwelts`ORLWER'ifs licable
GEOLOGIC EXP LO fV"�'1 lO N FROM TO DIAMETER THIC[INESS MATERIAL
ft. ft. In
Company Name
,1G INNER CASING OR'T-UBING` eotbermalclosed-lod °:
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 14.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
,17.SCREEN.,..,,H?
Water Supply Well: FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 14.0 ft• 24.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18r GROUT '
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 8.0 ft' PORT LAND BENTONUE SLURRY
INMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
`19..SAND/GRAYEt"PACK(if a lic"stile ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 12.0 1" 24.0 rt. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING',I OG attic)radditiotiil sheets if necessa' `-„
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUrock a grain size,etc.
0.0 ft• 5.0 ft. _ RED/ORANGE CLAY
4.Date Well(s)Completed: 05/04/22 Well ID# PZ-C 5.0 ft• 20.0 It BROWN PWR
5a.Well Location: 20.0 ft. 24.0 fl. GRAY ROCK
DAVIDSON COUNTY LANDFILL ft. ft.
Facility/Owner Name Facility ID#(if applicable) fL ft.
1242 OLD US HIGHWAY 29 THOMASVILLE 27360 ft. ft.
Physical Address,City,and Zip ft. ft.
DAVIDSON 21.REMARKS,-s
County Parcel Identification No.(PIN) BENTONIfE SEAL-8.0-12.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35o 51' 11.62"` N 80o 10' 34.66" W 6 1""'f 05/19/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certijy that the ivell(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 coP),
If this is a repair,fill out known ivell construction information and explain the nature ofthe ofthis record has beenprovided 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 w Irtruction info
construction,only I GW-I 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 �022
9.Total well depth below land surface: 24.0 (ft.)
T'or multiple wells list all depths ifeli erent(example-3@200'and 2@100) Submit this GW-I within 30 days of well completion per the following:
14.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
!f
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
water level is above casing,use"+"
11.Borehole diameter'' 6.0 (in.) 24b.For Injection Wells:Copy to,DWR,Underground Injection Control(NC)
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(gP m) Method of test' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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