GW1-2022-05201_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.�WTERZONES�:, ,
Well Contractor Name FROM TO DESCRIPTION
�
A - 3098 ft. ft.
ft. ft.
NC Well Contractor Certification Number ,v dy q 15.'OUTER CASING for multi-cased wells'OR LINER if a licable
GEOLOGIC EXPLORATION �E 4.�;0 I VE FROM To DIAMETER TTIICIavEss MATERIAL
ft. fL in.
Company Name MAY 3 1 2022
16.INNER CASING OR TUBING eothermal closed-loo -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC1Fd8WW "17� 'qV-'W t(J' Unj1 0.0 ft. 10.0 ft. 2.0 in' SCH 40 PVC
3.Well Use(check well use): DkVQ/-30G ft. ft. in.
Water Supply Well: 17:SCREEN' �.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑MunicipaUPublic 10.0 ft' 60.0 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
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fl. 4.0 It' PORTLAND BENTONITE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
=19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 8.0 ft' 60.0 It' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG.attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,gruin sire,etc
0.0 ft. 10.0 ft- RED CLAY
4.Date Well(s)Completed: O4/19/22 Well ID# MW-11 10.0 ft- 21.0 1" BROWN SILTY CLAY
5a.Well Location: 21.0 It' 60.0 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-4.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35e 52' 32.86" N 78e 53' 05.78" W Ae 05/19/22
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance Tvith
7.Is this a repair to an existing well: ❑Yes or l!lNo ISA NCAC 02C.0100 or ISA 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 ofthis 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
constriction,only I 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: 60.0 (ft)
For multiple wells list all depths ifdi,jferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
20.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
/frvater level is above casing,use"+"
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.0 (in,) 24b.For Injection 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:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018