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HomeMy WebLinkAbout__20220311 (36) 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