GW1-2022-03334_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: it
JOHNNY BURR 14.WATER ZONES l I.
Well Contractor Name FROM TO DESCRIPTION
A - 3098 ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased-wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. i '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.U/C.County,State,Variance,etc.) 0.0 ft. 5.0 ft. 1.0 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 5 0 ft. 25.0 ff. 1.0 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 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 3.0 ft' PORTLANDaENTONtrE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft- 25.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft. i i
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) (10ther(explain under 421 Remarks) FROM TO DESCRIPTION color,baldness,soil/mck type,gmin sin,etc.
0.0 ft• 2.0 fL GRAVEL
4.Date Well(s)Completed: 10/25/21 Well ID# OW-3 2.0 R. 7.0 It. BROWN SILTY CLAY
5a.Well Location: 7.0 ft. 9 0 ft. GRAY/BROWN CLAYEY SILT
BEST PRICE CLEANERS 9.0 ff• 250 ff• BRQ0 LAIEQJ
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
6820 DAVIS CIRCLE RALEIGH 27613 ft. ft.
Physical Address,City,and Zip ft. ft.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-4.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***OBSERVATION***
(if well field,one latAong is sufficient) 22.Certification:
350 51' 51.53" N 780 42' 39.26" W 6 10/29/21
6.Is(are)the well(s)• INPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing This form,/hereby certify that the snell(s)Bras(ivere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or INNo ISA NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,Jill out known urll construction information and explain the native ofthe ofthis record has been provided to rite well owner.
repair under 021 remarks section or on the back q/'this Jbrnt.
23.Site diagram or additional well details:
8.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page Ito 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: 25'0 (ft.)
Por multiple me//s list all depths iJ'dierent(example-3 tt 200'and 2@I00') Submit this CW-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: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f ivoter level is above casing,use"+" i
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy to1DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AUGER 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 I er 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018