GW1-2022-05179_Well Construction - GW1_20220531

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES,
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098 ft. ft.
NC Well Contractor Certification Number RECEIVED
E 15.OUTER CASING for multi.-cased)"wells OR-LINER if;a able)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
MA)fto ! 2022 0.0 ft• 66.0 ft. 2.0 in SCH 40 PVC
Company Name
16.INNER CASINGOR TUBING"cothermal closed-loop)
2.Well Construction Permit#: InfOftaria 4an Firrnzav=.»1 t..r FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(1.e.UIC,County,StatwN WOCW 0.0 ft. 85.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use):
ft. ft.
Water Supply Well: '17.SCREEN '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 85.0 1" 90.0 It. 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ,
❑hri ation ❑Wells>100,000GPD FROM TO. MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It. 79.0 ft' PORTLANDaENTONRE SLURRY
OMonitoring ❑Recovery 0.0 It. 66.0 It. PORTLANDaENTONITE SLURRY
Injection Well: ft. ft.
[]Aquifer Recharge ❑Groundvvater Remediation
�-19.SAND/GRAVELi
PAC K ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 83.0 ft. 90.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING L'OG attach additional sheets if necessary),,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiltrock type,grain size,etc.
0.0 ft. 4.0 ft. RED CLAY
4.Date Well(s)Completed: 04/19/22 well ID# MW-79 4.0 It. 10.0 ft. BROWN SILTY CLAY
5a.Well Location: 10.0 It. 90.0 ft. BROWN MUDSTONE
JMC- USA ft. ft.
facility/Owner Name Facility ID#(if applicable) ft. ft.
1 INNOVATION DRIVE RESEARCH TRIANGLE 27709 ft. ft.
Physical Address,City,and Zip ft. ft.
WAKE 21.REMARKS"_ ' -
County Parcel Identification No.(PIN) BENTONIfE SEAL-79.6-83.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 52' 32.86" N 780 53' 05.78" W 'u" 05/19/22
6.Is(are)the well(s): 191'ermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or INNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well oivner.
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 provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 90.0 (ft)
For multiple wells list all depths ifdifferent(example-3@200'and 1@100D Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.0/10.0 (in) 24b.For li iection Wells:Copy to DWR,Underground Injection Control(IUC)
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 installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018