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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES 1
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 3098 ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft• 48.0 ft• 6.0 in. SCH 40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WM0501462 FROM TO _ DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 50.0 ft• 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
I Well: 17.SCREEN
Water Supply y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 50.0 ft• 55.0 ft• 2.0 in. .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. 39.0 ft• PORTLAND BENTONITE SLURRY
MMonitoring ❑Recovery 0.0 ft• 48.0 ft. PORTLAND BENTONITE SLURRY
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
❑Aquifer Test ❑Stormwater Drainage 49.0 ft. 55.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0.0 ft. 2.0 ft• GRAVEL
4.Date Well(s)Completed: 01/14/22 Well ID# DW-1 2 0 ft. 4 0 ft• TAN/BLACK CLAY
5a.Well Location: 4.0 ft. 55.0 ft• BROWN MUDSTONE
J & K FOODMART ft. ft• MAK I I ZOZ7
Facility/Owner Name Facility ID#(if applicable) ft. ft. Y
5035 NC-96 OXFORD 27565 ft. ft• .
Physical Address,City,and Zip ft. ft.
GRANVILLE 21.REMARKS ,
County Parcel Identification No.(PIN) BENTONITE SEAL-39.0-49.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification: Q
36° 16' 54.07" N 78° 34' 25.23" W 1''?7' '�J � 01/25/22
6.Is(are)the well(s): EPermanent or OTemporary 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: ❑Yes or l No I5A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a cow
If this is a repair,fill out known well construction information and explain the nature of the of this record has been prorided to the well owner.
repair under#2I remarks section or on the back of this firm.
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: 55.0 (ft.)
For multiple wells list all depths if different(example-3@200'and 2 rt!00') Submit this GW-1 within 30 days of well completion per the following:
27.0 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: 12.0/6.0/7.875 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(lUC)
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 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:
V
Fonts OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018