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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
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 1 MATERIAL
ft. ft. in.
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.WC,County,Stale,Variance,etc.) 0.0 ft. 10.0 ft 2.0 ' 'n• SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft' 25.0 ft. 2.0 in' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
0 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. 3.0 ft• PORTLANDBENTONITE SLURRY
Monitoring ❑Recovery ft. .' ft.
Injection Well: '
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applit able)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 8.0 ft. 25.0 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.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft' 6.0 ft' TAN CLAY
4,Date Well(s)Completed: 01/14/22 Well ID# MW-8 6.0 ft• 25.0 ft* BROWN MUDSTONE
ft. ft.
5a.Well Location:
J & K FOODMART ft. ft. 1'
Facility/OwnerNante Facility lOt(if applicable) ft. ft. I MAR 1 4 2fl2�
5035 NC-96 OXFORD 27565 ft. ft. I
Physical Address,City,and Zip ft. ft. _ . .
GRANVILLE 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL 3.0 8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:36° 16' 54.59" N 78° 34' 26.52" W fr?7' -6'' ' 01/25/22
6.!stare)the well(s): OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo /5A NCAC 02C.0/00 or/5A NCAC 02C.0200 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 well owner.
repair under-2I 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 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: 25.0 (ft.)
For multiple wells list all depths if different(example-3 ct 00'and 2 ct/00') Submit this GW-1 within 30 days of well completion per the following:
12.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6.0 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-I636
12.Well construction method: 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 producingover 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: i
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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