GW1-2022-05204_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name y
�. 4, 9y ft. ft
_
NC Well Contractor Certification Number ty ��22 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION MAY d FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name y1 � � �f� � y 16.INNER CASING OR TUBING(geothermal closed-loop)
t�2.Well Construction Permit#: FROM I TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stare,Variance,etc.) 0.0 ft. 27.0 ft- 2.0 1O SCH 40 PVC
3.Well Use(check well use): % ft. in.
Water Supply Well: 17.SCREEN,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 27.0 il' 37.0 ft. 2.0 in- •010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT MECHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 23.0 ft- PORTLAND BENTONITE SLURRY
IEMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a IcabEe
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 25.0 ft. 37.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sairlrock type rain size,etc.
0.0 fr• 9.0 ". RED/ORANGE CLAY
4.Date Well(s)Completed: 04/28/22 well ID# PZ-E 9.0 fr. 37.0 ft. BROWN SILTY PWR
Sa.Well Location:
ft. ft.
SOUTH WAKE LANDFILL ft. %
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
6330 OLD SMITHFIELD ROAD APEX 27539 ft. ft.
Physical Address,City,and Zip
ft. ft.
WAKE 21.REMARKS "
County Parcel Identification No.(PIN) BENTONITE SEAL-23.0-25.0 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 78e 50' 41.08" W � "� 05/19/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the tvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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 of the of this 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 1 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: 37.0 (ft.)
For multiple wells list all depths tfdiereni(example-3@200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 22.0 (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(gP m) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
�I I
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018