GW1-2023-00738_Well Construction - GW1_20230113

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES F !
Well Contractor Name �` _ q -. 4 FROM TO DESCRIPTION
l J < ' F s e t ft.
A - 3098 '�
n,
M3 ft. ft. L,
NC Well Contractor Certification Number J AN i `1 15.OUTER CASING for rnulfi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION s Unit FROM TO DIAMETER THICKNESS MATERIAL
f..., -s:... J ft. ft. in.
Company Name ;t:,::.,.. '��'l..i'�tJ�%
16.INNER CASING OR TUBING `eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perntils(/.e.UIC.County,Stale,Variance,etc.) 0.0 ft. 20.0 ft. 2.0 hn' SCH 40 PVC
3.Well Use(check well use): ft. B. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 ft' 30.0 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
❑lrrl atlon ❑Wel Is> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 11.0 ft' PORTLANDBENTONITE SLURRY
25Monitoring ❑Recovery R. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19,SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 16.0 ft 30.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
0.0 ft• 1.0 ft• BLACK TOPSOIL
4.Date Well(s)Completed: 08�19/22 Well ID# IW-28 B 1.0 ft 8.0 ft' GRAY CLAY
5a.Well Location: 8.0 ft' 10.0 ft' GRAY PWR
EATON CORPORATION 10.0 ft 30.0 rt• GRAY ROCK
Facility/Owner Name Facility]DO(if applicable) ft.
2564 DURHAM ROAD ROXBORO 27573 ft. ft.
Physical Address,City,and Zip ft. ft.
PERSON 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 11.0-16.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latlong is sufficient) 22.Certification:
360 21' 32.60" N 780 59' 04.59" W 6&4Y 1 09/01/22
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerlify that the wells)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cohw
//71is is a repair,/ill out known well construction n formation and explain the nature of the of this record has been provided to the well owner.
repair under!!21 remarks.section or on the back q/lhis 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 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 pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30.0 (ft.)
hbr multiple ire/1s list all depths iI dijjerent(example-3 a@200'and 2 c@r 100,) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 11.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Statler ic
a above casing,below
use" Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
ffi11.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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: p,
13b.Disinfection type: Amount:
For G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018