GW1-2021-03246_Well Construction - GW1_20210628

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1 i i
BRIAN THOMAS 14.WATER ZONES t :
Well Contractor Name FROM TO DESCRIPTION I
ft ft.
A - 2581 ^ 1
NC Well Contractor Certification Number ,�\V ,p �n9\y\A 15.rOUTER CASING for multi-cased wells ORiLINER if.a livable
GEOLOGIC EXPLORATION J :AnAC WSS� FROM TO DIAMETER' THICKNESS MATERIAL
0.0 .ft. 50.0 ft. 6.0 in. I SCH 40 PVC
Company Name 1(I++ R
VA0 QV`t 16.INNER CASING OR TUBING ebthermal closed-loop)
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stare,Variance,etc) 0.0 ft. 64.0 ft. 2.0 '"' SCH 40 PVC
3.Well Use(check well use): ft. ft, in.
,17.SCREEN , l, I
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 64.0 ft. 74.0 ft. 2.0 r"•I 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft, in.I
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT 1 11,
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL 9 iEMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 49.0 ft. PORTLANDBENTONITE SLURRY
25Monitoring ❑Recovery 0.0 ft. 50.0 ft' PORTLANDBENTONITE SLURRY
Injection Well:
rt. rt.
❑Aquifer Recharge []Groundwater Remediation
19:SAND/GRAVEL PACK`if a 7iciible
❑Aquifer Storage and Recovery ❑Salinity Baffier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 61.0 ft. 74.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft. I 'I
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG.attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTIONcolor hardness,soil/rockrain size,etc.
0.0 ft. 13.0 ft. I RED SILTY CLAY/BOULDERS
4.Date Well(s)Completed: 05/26/21 well ID# MW-311 BR 13.0 ft. 27.0 ft. BLACK SILTY SAND
Sa.Well Location:
27.0 ft. 45.0 ft. ( PWR
DAN RIVER STEAM PLANT 45.0 ft• 74.0 ft- a ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft. j
524 SOUTH EDGEWOOD ROAD EDEN 27288 ft. ft.
Physical Address,City,and Zip ft. ft.
ROCKINGHAM 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-49.0-61.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
360 29' 29.55" N 790 43' 11.04" W i_,_jam;,; -
� 06/09/21
6.Is(are)the well(s)• (Permanent or ❑Temporary Signature of Certified Well Contractor + Date
By signing this form,1 hereby certify that�heiwe//(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or I5A NCAC 01G.p100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the uv 11 owner.
repair under 421 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 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: 74.0 (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') Submit this GW-1 within 30 daysrf:well completion per the following:
25.0 24a. For All Wells: Original for to Division ision of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 1
11.Borehole diameter 12.0/6.0/7.875 (in) 24b.For Injection Wells:Copy to' DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/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'bver 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018