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HomeMy WebLinkAbout__20220311 (29) WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: JOHNNY BURR 14.WATER ZONES f. Well Contractor Name FROM TO DESCRIPTION rt. ft. ! A - 3098 ft. ft. ` NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if apQIlicable) GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS I MATERIAL ft. ft. in. Company Name 16.INNER CASING OR TUBING (geothermal closed-loop) 2.Well Construction Permit#: FROM TO DIAMETER . THICKNESS MATERIAL List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) 0.0 ft. MO ft. 2.0' in' SCH 40 PVC 3.Well Use(check well use): ft. ft. in. Water Supply Well: 17.SCREEN PP yFROM TO DIAMETER SLOT SIZE _ THICKNESS , MATERIAL ❑Agricultural ❑Municipal/Public 11.0 ft. 26.0 ft' 2.0 1n' .010 SCH 40 PVC ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ❑Irrigation ❑Wells>100,000 GPD FROM , TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0.0 ft. 5.0 ft. PORTLAND BENTONITE SLURRY IMMonitoring ❑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 0 Aquifer Test ❑Stormwater Drainage 9.0 it• 26.0 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,soil/rock type,grain size,etc.) ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2l Remarks) 0.0 ft. 7.0 ft. RED/ORANGE CLAY 4.Date Well(s)Completed: 10/06/21 Well ID# MW-3 7.0 ft. 26.0 ft' TAN SILTY CLAY ft. ft. 5a.Well Location: . -- A CLEANER WORLD ft. ft. Facility/Owner Name --Y- Facility ID#(if applicable) ft. ft. MAR tl R 1 1 ?02 3735 PETERS CREEK PARKWAY WINSTON SALEM 27127 ft. ft. 1Yf4iC Physical Address,City,and Zip ft. ft. FORSYTH 21.REMARKS , County Parcel Identification No.(PIN) BENTONITE SEAL.5.0-9.0 FEET 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certification: 36° 01' 10.68" N 80° 15' 36.90" W G 1j&ti 10/19/21 6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: DYes or EINo l5A 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 of this record has been provided to the well owner. repair under#21 remarks section or on the back of this farm. 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 I 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: 26'0 (ft.) For multiple wells list all depths ifd different(example-3 a 200'and 2 r@r l00') Submit this GW-1 within 30 days of well completion per the following: 17.0 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 If water level is above casing,use". 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! 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 27699-1 61 1 13a.Yield(gpm) Method of test: 13b.Disinfection type: „_ Amount: , Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 6-6-2018