GW1-2022-05180_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i� JOHNNY BURR aa:wATER�zONEs Y. �.�;
Well Contractor Name FROM TO DESCRIPTION
A - 3098 ft. ft.
G 'a�..�.�� � .�&..-t ft. ft.
NC WellConhactorCertificationNumber ��� ���� �A&OUTERCASING for`multi=caseil"i Hs ORLINER`iEa' licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICIavESS MATERIAL
ft. ft. in.
Company Name lfl�fi*F3a'A�n"l✓i:Curer'^�Unp
Y6sINNER CASING`OR'TUBING;�"eothermal closed
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 It. 15.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
'17.`SCREEN
Water Supply Well:
,z..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipa]/Public 15.0 ft' 25.0 ft. 2.0 t"' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) is GROUT 77
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It. 11.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
ti 19.SANWGRAVEL�
PACK`if a licatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 13.0 It. 25.0 It. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer �-20.�DRILLING'LOG attacli additionifilieets if necessa '
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft' 3.0 ft- RED/ORANGE SILTY CLAY
4.Date Wells)Completed: 04/28/22 Well ID# PZ-H 3.0 ft. 10.0 ft. BROWN SILTY PWR
5a.Well Location: 10.0 ft. 16.0 ft' BROWN MUDSTONE
SOUTH WAKE LANDFILL 16.0 It. 25.0 ft. GRAY ROCK -
Facility/OwnerName Facility ID#(if applicable) ft. ft.
6330 OLD SMITHFIELD ROAD APEX 27539 ft. ft.
Physical Address,City,and Zip ft. ft.
WAKE 21 REMARK&I .
County Parcel Identification No.(PIN) BENTONITE SEAL-11.0-13.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification:
35e 40' 53.11" N 780 50' 41.08" W ` 05/19/22
6.Is(are)the well(s): APermauent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.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 owner.
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 I GW-1 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.)
For multiple wells list all depths ifdierent(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 casing: 13.0 (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: 8.0/4.0 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/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