GW1-2023-02236_Well Construction - GW1_20230307

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well Contractor Information:
JOHNNY BURR 14:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098
fr. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ilicable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. f[. in.
Company Name
16iINNER CASING OR TUBING• eothermal closed-loo
2.Well Construction Permit#: WM0501537 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.U1C,County,Stale,Variance,etc) 0.0 ft. 37.0 ff 2.0 t"' 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 37.0 ft' 52.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 30.0 ft- PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
El Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 35.0 It. S2.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRiLLiNG'LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soillawk e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft. 1.0 ft. BLACK TOPSOIL
4.Date Well(s)Completed: 02/02/23 Well ID# MW-14 1.0 ft. 9.0 ft. PWR
5a.Well Location: 9.0 ft. 52.0 f" GRAY/BROWN BEDROCK
VANCE COUNTY LANDFILL fr. ft.
Facility/Owner Name Facility ID#(if applicable) fL ft.
3181 NC - 39 HENDERSON 27537 ft. ft.
a. r•nn
Physical Address,City,and Zip ft. ft. \ '•1 . 3
VANCE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certification:
360 22' 06.64" N 780 25' 11.48" W 02/10/23
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the tvell(s)was(here)constructed in accordance midi
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known well construction information and explain the nature of the oJ7his record has been provided to the mell owner.
repair under 921 remarks section or on the back ofthis 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-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: 52.0 (ft.)
For i n iliple wells list all depths ifdierent(example-3 t@i 200'and 2 rr 100') Submit this GW-1 within 30 days of well completion per the following:
<47.34 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Iftvater level is above casing use"+"
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
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
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:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018