GW1-2022-09590_Well Construction - GW1_20221021

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES E i
Well Contractor Name FROM TO DESCRIPTION
tt. tt. E
A - 3098
NC Well Contractor Certification Number
15.OUTER CASING for multi-casedhc ells)OR LINER if a rlicable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
fr. ft. in.
Company Name ft.
INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable yell con.strucuon permits(i.e.1;1C,Count..Slate. Marimtce,etc.) 0.0 ft. 12.0 ft' 2.0 in. SCH 40 PVC
3.Well Use(check well use): R. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 12.0 ft' 22.0 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
❑Irrigation ❑Wel1S> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD S AMOUNT
Non-Water Supply Well: ,0.0 ft• 3.0 ft. AQUAGUARD SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
fr. ft.
❑Aquifer Recharge ❑GroundwaterRemediation
19.SAND/GRAVEL PACK(if a I tlicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO M1IATERIAL EMPLACEMENT MF,THOD
❑Aquifer Test ❑Stormwater Drainage 10.0 ft. 22.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. R.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM to DESCRIPTION(color,hatiness,soil/rock tyre, rain sire.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 22.0 ft" BROWN CLAYEY SANDY SILT
4.Date Well(s)Completed: 09/08/22 Well ID# CCR-27S
5a.Well Location:
BUCK STEAM STATION tr. rt.
Facility/Owner Name Facility IDN(ifapplicable) ft. ft.
1555 DUKEVILLE ROAD SALISBURY 28146 ft. ft. Prin, *" g
Physical.address,City.and Zip ft. ft.
ROWAN 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL- 3.0 10.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lit/long is sufficient) 22.Certification:
350 42' 43.01" N 800 22' 05.52" W �u� 10/10/22
6.Is(are)the.well(s): INPermanent or ❑"Temporary Signature of Certified Well Contractor Date
By signing ibis tarn,.I herein cerliti,Thal the n'e1/(1)n'as(t,ere)conslrucled in ac('orda„c't'❑'idi
7. Is this a repair to an existing Nell: ❑1`es or [5No l A AICAC 02C.0100 or 15.4 I'('AC 02C..0200 Well Construction Slandards and d,ul o cope
If 1his is a repair.till ow knot,n well cot.nnuclion inlinwiation and explain the nature al'ilie of this record has been provided In die it corner.
repair under=21 remarks section or on the hack of dtis J n-liv
23.Site diagram or additional wellidetails:
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 inlit
construction,only I GW-I is needed. Indicate TOTAL NUMBER of\yells (add'See Over ill Remarks Box).Yotit may also attach additional pages i1'necessan.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 22.0 (ft.)
Rr,nu/tip/c,,ells/isi all depths ij</i/Jitre•ut(example-3@200'and 2(rtr100') Submit this GW-I within 30 days of well completion per the following:
2.0 24a. For All Wells: Original torn I to Division oh Water Resources (DWR).
10.Static water level below top of casing: (ft.) Inf-ormation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1l'traler level i.s ahore caaitt,,„use..^
Il.Borehole diameter: 8'0 (in.) 24b. For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC.Raleigh.NC 27699-1636
AUGER - I
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.nuger,rota,)-,cable,direct push.etc.) county environmental health department of the county where installed
FOR 1VATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC.Raleigh!NC 27699-1 61 1
13a.field(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6 21)1 S
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