GW1-2022-05399_Well Construction - GW1_20220311

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 0
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
.
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098
rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
e. fr. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC.County,State, Variance,etc.) 0.0 ft. 15.0 rt. 2.0 in. 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 ft' fr, in.
15.0 30.0 2.0 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 9.0 fr. PORTLANOBENTONITE SLURRY
OMonitoring ❑Recovery fr. ft.
Injection Well:
fr. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 13.0 ft- 30.0 ir' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control fr. fr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,ginin size,etc.
0.0 rt 8.0 rt RED CLAY
4.Date Well(s)Completed: 01/31/22 Well ID# MW-14 8.0 a. 30.0 ff RED/ORANGE PWR
Sa.Well Location:
rr. tr.
PROPST SUPERETTE q qq
Facility/Owner Name Facility ID4(ifapplicable) ft. ft. MAR 1 202?
3462 SPRINGS ROAD NE HICKORY 28601 ft. ft.
Physical Address,City,and Zip
tr. ft.
CATAWBA 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-•9.0-13.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
350 45' 53.24" N 810 16' 00.89" W 02/18/22
6.Is(are)the well(s): TPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing lhi.s form,I hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!9No I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lflhis 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 rentarks 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 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: 30.0 (ft.)
For multiple wells list all depths t(diJjerent(example-3 ct 200'and 2 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 46•0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1Jlrater level is above casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR 24c.For Water Supply and Openi'Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depart ment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinglover 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:
4
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018