GW1-2023-02026_Well Construction - GW1_20230303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
rc. ft.
NC Well Contractor Certification Number n
MAR A c` L 15.OUTER CASING for multi-cased wells OR LINER if a ilicable
GEOLOGIC EXPLORATION MAR ''j FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name �r^.^.',,': ;F:J
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: V.� ' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft. 35.0 ft. 2.0 ' 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 35.0 f" 50.0 ft. 2.0 t"' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&ADIOUNT
Non-Water Supply Well: 0.0 ft. 27.0 ft' PORTLAND BENTONrrE SLURRY
OMonitoring ❑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 MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 33.0 ft. 50.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothenmal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.)
0.0 ft. 3.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 01/23/23 Well ID# MW-1 R 3.0 ft- 9.5 1" TAN SILTY CLAY
Sa.Well Location:
9.5 f" 48.0 ft' TAN/PINK SILTY CLAY
PITT STOP 48.0 ft. 50.0 ft' TAN/WHITE SILTY CLAY
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2946 US - 70 MORGANTON 28655 ft. ft.
Physical Address,City,and Zip ft. ft.
BURKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-27.0-33.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
350 44' 39.49" N 810 36' 42.81" W �° 02/10/23
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or INNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stanrlardv and that a copy
!f dnis is a repair,fill out known well construction information and explain the nature of the ofthis record hay been provided to the well owner.
repair under 921 ren+arks section or on the back of this fornn.
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-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: 50.0 (ft.)
For nn+hiple wells list all depths ifdifferent(example-3@200'and 2 a 100D Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 40.0 (ft) 24a. For All Wells: Original fort to Division of Water Resources (DWR),
lfwaterlevel is above casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in,) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
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 ofthe 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:
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018