GW1-2021-00748_Well Construction - GW1_20210401

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: Fr,
BRIAN THOMAS °�� � 14.WATER ZONES 1 I
a-Well Contractor Name FROM TO DESCRIPTION'.
��"� ft. ft.
A - 2581
NC Well Contractor Certification Number 6n3
PrGGeS I5.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION �Pt$OIC�3tOnt�JF`!QT1 FROM TO DIAMETER! THICKNESS MATERIAL
t� ft. ft. iin.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER; I THICKNESS I MATERIAL
List all applicable a ell construction permits(i.e.UIC.Countyt State.Variance,etc) 0.0 ft- 37.0 ft- 2.0 lin. SCH 40 PVC
3.Well Use(check well use): R. ft. !in.
Water Supply Well: 17.FROM SCREENTO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
37.0 47.0 2.0 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL i EMPLACEMENT METHOD&AMOUNT
Non-Water Supply 1Vell: 0.0 ft. 29.5 ft' PORTLAND BENTONITE SLURRY
MMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 34.0 ft• 47.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiVrock e, rain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft. 11.0 ft- RED SILTY CLAY
4.Date Well(s)Completed: 03/1 7/21 Well ID# MW-10 11.0 ft. 19.0 ft. TAN SILTY SAND
5a.Well Location: 19.0 ft' 47.0 ft. PWR
CHARAH - BRICKHAVEN ft. ft.
Facility/Owner Name - Facility ID#(ifapplicable) ft. ft. I
1271 MONCURE FLATWOOD ROAD MONCURE 27559 ft. ft.
Physical Address,City,and Zip ft. I ft.
CHATHAM 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL 29.5-34.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
350 59' 79.08" N 790 02' 19.91" 1V
03/24/21
6.Is(are)the well(s): INPermanent or ❑Temporary Signature ofCertified Well Contractor Date
Hy signing this form,I hereby certify that the nie/lis)eras(were)constructed in accordance nruh
7.Is this a repair to an existing well: 01'es or ONo 15A NCAC 01C'.0/00 or ISA NCAC 01C.0200 Well Construction Standards and that a copy
ll'this is a repair,Jill out known well construction inJimnnation and explain the nature ot'dne oJ'this record has been provided to the well oirner.
repair under 711 remarks section or on the back oJ'this fora.
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-I 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: 47.0 (ft.)
p p J JJ (example- ) Submit this GW-1 within 30 days of well completion per the following:
(br multiple u�elLr list all depths i do event eruct le-3 t 100'and 1! l0l1' Y P P g
10.
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24a. For All Wells: Original form to Division of Water Resources (DWR),
lfualer level is abase caring,use Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: 8.0 (in.) 24b. For lnjection Wells: Copy to DWR, Undet-ground 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 of the county where installed
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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.field(gpm) Method of test: I
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13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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