GW1-2022-03333_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. j
A - 3098 ft. ft. I!
NC Well Contractor Certification Number '
15.OUTER CASING for multi-caded;wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. fr. � :in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
/.ist all applicable well construction permits(i.e.U/C,County.Stale,Variance,etc) 0.0 ft• j•Q ft- 4.0 '"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 "' 15.0 n. 4.0 in. .020 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 3.0 ft. PORTLANDBENTONLTE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PAC K ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft 15,0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
❑Geothermal(Heating/Cooling Return) L'JOther(explain under#21 Remarks)
0.0 ft- 1.0 fr. ASPHALT/GRAVEL
4.Date Well(s)Completed: 10/27/21 Well ID# SVE-1 1.0 ft. 9.0 ft. BROWN SILTY CLAY
5a.Well Location: 9.0 fr' 11.0 fr• GRAY/BROWN CLAYEY SILT
BEST PRICE CLEANERS 11.0 ft- 15.0 ft. f j BROWN CLAYEY SILT
Facility/Owner Name Facility ID#(if applicable) -
6820 DAVIS CIRCLE RALEIGH 27613 ft. fr.
Physical Address,City,and Zip ft. ft.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL_3.0 4.0 FEET
***SOIL VAPOR EXTRACTION***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hit/long is sufficient) 22.Certification:
350 51' 51.53" N 780 42' 39.26" W 10/29/21
6.Is(are)the well(s): (EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!9No 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known well construction information and explain the nature of the ofihis record has been provided to the well owner.
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repair under 921 remarks section or on the back g/'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).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15.0
For mulliple wells list all depths ifdifferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
11.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ftJ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" !
24b. For Injection Wells:Copy to!;DWR,Underground Injection Control (IUC)
11.Borehole diameter: 8.0 (in,)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loon 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 Ives 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