GW1-2022-08712_Well Construction - GW1_20220527

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
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKINESS MATERIAL
ft. ft. in.
Company Name
'16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 13.0 ft. 2.0 In' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM
SCREEN
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 13.0 ft• 23.0 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) 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0•0 ft. 7.0 It' PORTLAND BENTONDE SLURRY
IMMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
49.SAND/GRAVEL?PACK ifa licablr.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage 11.0 ft' 23.0 ft. 20-40 FINE SILICA SAND
❑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 I TO DESCRIPTION color,hardness,soillrock type,grain size,etc
0.0 ft- 3.0 fr• RED/ORANGE CLAY
4.Date Wells)Completed: O5/O4/22 Well EM PZ-D 3.0 It- 10.0 Il• BROWN/WHITE SANDSTONE
Sa.Well Location: 10.0 It. 23.0 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-7.0-11.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35e 51' 11.62" N 80e 10' 34.66" W 6 05/19/22
6.Is(are)the well(s): OPermanent 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 MNo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standar&_amJthat a copy
If this is a repair,fill out known ivell construction information and explain the nature of the ofthis record has been provided to the ivell owner. Direpair 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 r1l��consttrttctio .tk'r fo�
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'nessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 23.0 (ft.
For multiple wells list all depths ifdierenr(example-3@200'and 2@100D ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 13.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater 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 hnection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR
24c.For Water Supply and Open-Loop Geothermal Return We11s: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 27699-1
13a.Yield(gpm) Method of test: 111
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018