GW1-2022-03279_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
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Well Contractor Name FROM TO DESCRIPTION
A - 3098
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased welts OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
( in.
Company Name '
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 5.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use):
ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public S fr. 15.0 ft' 2.0 in' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl atlon ❑Wel Is>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 ft' PORTLAND BENTONRE SLURRY
INMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
.19.SAND/GRAVEL PACK if a licable
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft. 15.0 ft. 20-46 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(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,gmin sae,etc.
0.0 ft• 1.0 It. GRAVEL
4.Date Well(s)Completed: 02/1 0/22 Well ID# MW-3 1.0 ft. 6.0 ft- GRAY SAND
5a.Well Location: 6.0 ft- 10.0 ff ROCKY BACKFILL
ACME CLEANERS 10.0 ft. 15.0 ft. TAN/YEUOW CLAY
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
MAR 14
200 SOUTH BODDIE STREET NASHVILLE 27856 rt. rt.
Physical Address,City,and Zip
NASH 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL' 3.0-'4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 58' 24.80" N 770 58' 06.24" W '�`�`� 02/18/22
6.Is(are)the well(s): [EPermanent or ❑Temporary 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 [!flNo 15A NCAC 02C.0100 or 15A NCAC 02C',.0200 Well Construction Standards and that a copy
If[his is a repair,fill out known well construction information and explain the nature ofthe ofihis record has been provided to the well owner.
repair under#21 remarks.section or on the back of this form. I
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-I 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: 15.0 (ft.)
For multiple wells list all depths ifdiiferent(example-3 ct 00'and tea 100')10. Submit this GW-1 within 30 days of well completion per the following:
7.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1fwater level is above caring,use"+" t
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11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
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
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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:
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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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