GW1-2022-05115_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 44.WATER ZONES
FROM TO DFSCRn'TION
Well Contractor Name ft. ft.
A - 3098 ft. It.
NC Well Contractor Certification Number 15:OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICIavESS MATERIAL
fr. fr. in.
Company Name 16.4NNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 It. 35.0 ft• 2.0 1° SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
47.-SCREEN-
Water Supply Well: FROM TO DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 35.0 ft. 55.0 It' 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
❑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- 31.0 ft- PORTLAND BENTONITE 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 33.0 It- 55.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
FROM
0. ft. T5.0 It. DESCRIPTION cBROWNsSILTYCLAY gamins,soillmcktype� sire,etc.
❑Geothermal(Heating/Cooling Return) �lOther(explain under#21 Remarks)
4.Date Well(s)Completed: 04/22/22 Well ID# PZ-6-2 5.0 It• 30.0 It• BROWN/TAN SILT
5a.Well Location: 30.0 % 55.0 ft. GRAY ROCK
WILKES COUNTY LANDFILL ft. ft.
Facility/Owner Name Facility ID#(irapplicable) ft. ft.
9219 ELKIN HIGHWAY ROARING RIVER 28669 ft ft.
fr.Physical Address,City,and Zip ft.
WILKES zL REMARKS-
BENTONITE SEAL-31.0-33.0 FEET
County Parcel Identification No.(PIN)
***PIEZOMETER***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
360 12' 27.47" N 80e 59' 24.00" ter 04/28/22
Signature ofCertified Well Contractor Aatea
6.Is(are)the well(s): 29Permanent or ❑Temporary I '
By signing this form,I hereby certify that the ivell(s)wcFs(u-4,L. � 1 t'd c ith
7.Is this a repair to an existing well: ❑Yes or 15No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards(and that a copy
Ifthis is a repair,fill out known ivell construction information and explain the nature ofthe ofthis record has been provided to the ivell owner. MAY 3 1 2022
repair under#21 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 proviq#0d�4U0hwetkcD39tsi1'tiplUdO
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach a(Vq J)Q0 if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 55.0 (ft)
For multiplewe/!s list all depths ifdtJj'erenl(example-3@200'and 2@I00) Submit this GW-1 within 30 days of well completion per the fallowing:
27 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
If water level is above casing,use••+••
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6'0 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR 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 rnstalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018