GW1-2022-08711_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR A4..WATERZONEse
Well Contractor Name FROM TO DESCRIPTION
A - 3098 ft. ft
ft. fA
NC Well Contractor Certification Number 15.OUTER CASING for mule-cased'wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICIavESS MATERIAL
ft. ft. in
Company Name
16.'INNER CASING OR TUBING eotheIr al closed-loop),
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(1.e.UIC,County,State,Variance,etc.) 0,0 ft, 24.0 ft- 2,0 rn SCH 40 PVC
3.Well Use(check well use): ft, ft. in.
Water Supply Well: `17.`SCREEN,`� , ,.
FROM TO DIAMETER" " SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 24,0 ft' 34.0 ft' 2.0 1" .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) _ 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 18.0 ft. PORTLANDBENTONITE SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 22.0 ft' 34.0 ft- 20-40 FINESILICASAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) []Tracer "20.DRILLING LOG`attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
0.0 ft. 2.0 ft- RED/ORANGE CLAY
4.Date Well(s)Completed: 05/04/22 Well ID# PZ-E 2.0 ft, 5.0 ft, BROWN PWR
Sa.Well Location: 5.0 ft' 10.0 ft. GRAY/WHITE SANDSTONE
DAVIDSON COUNTY LANDFILL 10.0 ft' 34.0 ft- GRAY ROCK
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'"O'01'
County Parcel Identification No.(PIN) BENTONITE SEAL-18.0-22.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 51' 11.62" N 800 10' 34.66" W 05/19/22
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)ivas(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or [!NNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known ivell construction information and explain the nature of fire of this record has been provided to the ivell owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details: LTV
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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional•qag if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS 01A i � �
9.Total well depth below land surface: 34,0 (ft,)
For multiple wells list all depths ifeli(jerent(example-3@200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10•0 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+"
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8,0/6.0 (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 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018