GW1-2022-03280_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES i.
Well Contractor Name FROM TO DESCRIPTION
ft. ft. k
A - 3098 a. a. '
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-case td wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,elc) 0.0 ft. 10.0 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 10.0" 20.0 It- 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 6.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ir. f.
Injection Well:
fr. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 8.0 ft• 20.0 ft' 20-40 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/evck e, rain size,etc.
0.0 ft• 1.0 ft• GRAVEL
4.Date Well(s)Completed: 02/1 0/22 Well ID# MW-2 1.0 ft• 5.0 fit- GRAY SAND
5a.Well Location: 5.0 rt. 8.0 ft. WHITE/GRAY SAND
ACME CLEANERS 8.0 ft• 200 ft• TAN/YELLOWCLAY
Facility/Owner Name Facility ID#(ifapplicable) -ft. ft. ` ,��- •"
200 SOUTH BODDIE STREET NASHVILLE 27856
Physical Address,City,and Zip ft. ft. MAR 14 027
NASH 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-6A-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
350 58' 24.80" N 770 58' 06.24" W �u'r't' 02/18/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this fornt,/hereby certify that the well(s)was(were)consiructed in occordonc•e with
7.Is this a repair to an existing well: ❑Yes or MNo I5A NCAC 02C.0100 or 15A NCAC 02C i0200 Well Construction Standards and that a copy
/f 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#21 remarks section or on the back otrthis 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).YoWmay also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20.0 (ft.)
For multiple wells list all depths if dilfereni(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easing: 7•0 (fL) 24a. For All Wells: Original forme to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1 f u ater level is above casing,use
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 departmeht 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: i
13b.Disinfection type: Amount:
k
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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