GW1-2023-00803_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR _
14.WATER ZONES } {
a`�;� f �v;~'s�' J'�',� ,FROM TO DESCRIPTION
Well Contractor Name
ft.
A - 3098 JAv g 2023
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NC Well Contractor Certification Number 15.OUTER CASING.for mul6-crt d wells OR LINER if a licable)
GEOLOGIC EXPLORATION If f iiY s,°^i1 ' rl 1 f FROM TO DIAMETER THICKNESS MATERIAL
- ft. ft. in.
Company Name '''''°'`�,'"��" '
16.INNER CASING'OR TUBING eothei'mal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,Stale,Variance,etc.) 0.0 ft 4.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water.Supply Well: 17.SCREEN,
FROM TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 4.0 ft' 14.0 ft' 2.0 t"' 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT
❑Irrl ation ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2.0 ft PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery ft. 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 3.0 ft 14.0 rr• 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 421 Remarks) FROM TO DESCRIPTION color,hardness,soa/mck type,grain size,etc.
0.0 ft. 0.5 ft. ASPHALT
4.Date Well(s)Completed: 10/04/22 Well ID# MW-3 0.5 ft. 1.0 e. GRAVEL
Sa.Well Location: 1.0 rr' 14.0 rf BROWN SILTY CLAY
NCDOT BUCKEYE SHED
Facility/Owner Name Facility ID#(ifapplicable) ft. ft '
52 LAKESIDE DRIVE BAKERSVILLE 28705 rt. It.
Physical Address,City,and Zip ft. ft.
MITCHELL 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-2.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one.lat/long is sufficient) 22.Certification:
350 59' 55.83" N 820 09' 20.84" W �"'Y 10/19/22
6.Is(are)the well(s): I!gPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the mell(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [5No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/fthis is a repair,fill out known well construction information 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 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 well construction info
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 necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 14•0 (ft.)
For multiple welts list all depths ifdifferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 4•0 (ft) 24a. For All Wells: Original foim to Division of Water Resources (DWR),
/flrater 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 Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR j
24c.For Water Supply and Opcn-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 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018