GW1-2022-05414_Well Construction - GW1_20220311

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM ft. TO ft. DESCRIPTION
A - 3098 ft. ft. P
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft. 40.0 ft. 6.0 i" SCH 40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable irell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 42.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 42.0 ft. 47.0 fr. 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
❑Irri ation ❑Wel Is>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 36.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery 0.0 ft- 40.0 ft' PORTLANDBENTONITE SLURRY
Injection Well:
fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(ifapplicible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 39.0 ft- 47.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
OGeothermal(Closed Loop) ❑Tracer 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• 1.0 ft• GRAVEL
4.Date Well(s)Completed: 10/12/21 Well ID# MW-1 D 1.0 ft• 18.0 ft. ORANGE SILTY CLAY
5a.Well Location: 18.0 ft. 36.0 f" BROWN SILTY CLAY
BRADSHER MINI MART 36.0 ft- 43.0 ft- GRAY ROCK
Facility/Owner Name Facility ID4(ifapplicable) 43.0 ft. 47.0 It. k BROWN/GRAY PWR.
5401 NC HIGHWAY 119 BURLINGTON 27217 ft. ft.hi AD 1
Physical Address,City,and Zip
ALAMANCE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL`r=36.0-39:O FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
360 13' 28.04" N 790 17' 53.22" W 10/20/21
6.Is(are)the well(s)• [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ieel/(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
/f this is a repair•fill out known well construction information and explain the nature of due of this record has been provided to the well owner.
repair under 121 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Yolu may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 47.0
For umuhiple wells list all depths ifdiJJerew(example-3 rt 200'and 2@ 100') Submit this GW-1 within 30 days of well completion per the following:
14.0 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
1Jlvaler level is above casing,use"+" i
11.Borehole diameter. 12.0/6.0 (i") 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AUGER/AIR 1
12.Well construction method:
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:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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