GW1-2021-00809_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.\Yell Contractor Information:
Jonathan R. Grubbs 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
FL (t.
3001
rt. rL
NC Well Contractor Certification Number 15.OUTER CASING for 7itIft sad welN OR LINER ifs Ewble
Terraquest Environmental Consultants, P.C. FROM TO DIAMETER THICKNESS MATERIAL
0 ft 5 fL 2 schedule 40 PVC
Company Name 16.INNER CASING OR TUBING mthermal closW-too
2.\Yell Construction Permit N: FROM TO DIAaf ETER THICKNESS MATERIAL
Lur all appbcable sell amsnuctmn prrmirs p-e.(IR,Comm;Stare, t'ariance,arc/ ft. R
3.Well Use(check well use): ft. R, in.
Water Supply Well: 17.SCREEN
FROM TO DIMIETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 20 D- 2 '° 0.010" Ischedule4O PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential water$upply(single) R 5 ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑hriation Dwells> 100.000 GPD FROM I TO I MATERIAL EMPLACFAIENTMFTHOD&AMOOYT
Non-Water Supply Well: 0 f. 1 fc Portland cement pour
OMonitoring []Recovery 1 fL 3 ru bentonite pour
Injection Well:
h. fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVELPACK , *ppnoble
OAgllifer Storage and Recovery ❑Salinity Barrier FROM TO IMATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3 fL 20 fL no 2 filter sand pour
❑Experimental Technology ❑Subsidence Control f. ft
❑Geolhenrial(Closed Loop) ❑Tracer 20.DRILLINGLOG amch additioodaheetaifoecwa
color,
❑Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION herdmn,eoiVrotkrrain�ire,eta.Other(explain under k2l Remarks)
0 fL 5 f° Orange/brwn coarse to mad sand abd clay
4.Date Well(s)Completed: 2/3/21 Well lns MW19 5 b. 10 It, light brown clay medium sand
5a.Well Location: 10 H' 15 ft light brown med sand moderate clay
Bunn Exxon 0-015307 15 fL 20 ff light gray clay with crse/med sand and mica
Facility/(Toner Name Facility lD:;ufapplicable) ft. R
300 MAIN STREET, BUNN NC 27508 ft. ft
Physical Address,City,and Zip ft. fL
FRANKLIN 2820-05-8360 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaVlong is sufficient) 22.Certification:
35.96039 N -78.25363 \\ Q 2/8/2021
6.Is(are)the well(s): (lPermanent or OTemporary. Signature of Certified Well Contractor Date
Hp ogmng rhosform,Ihereby errh that the.ell(s).ns prere/consrsuued maemn/ance wvh
7.Is this a repair to an existing well: ❑Yes or ONo ',"'1"�:q''s[""-15A NCAC 02C'.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/fihis rs a repair,fill out known xell consmstion information and uplain the nWWI .fl*,-. Qrrhis record has heen provided to the yell owner.
repair under,121 remarks section or on the hack ofdos form.
[[p 1 r23rtn rNtl hS�iteidiagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having dri slmt4f 1 f'y use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOI AL 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: 20 (ff) Submit this GW-1 within 30 days of well completion per the following:
For....duple rvelh list al/depths fd renr(exntnple-3@200'nn 12/&100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below tap oficasing: (IT) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If uwmer k,,,/is shove casing. ,,, -
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells: Cop) to DWR, Underground Injection Control BUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: solid stem auger
24c.For Water Supple and Open-Loop Geothermal Return\\'ells:Copy to the
u e-auger,mtary,cable,direct push ess) county environmental health department ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water N'ells producing over 100,000 GPD: Cops to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,INC 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Fonn GW-I Nonh Carolina Depanmem of Rnvironnienml Quality-Division of Water Resources Re...ed 6-6-2018