GW1-2022-05207_Well Construction - GW1_20220531

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
NC Well Contractor Certification Number R Ec"E I V E-D ft. ft.
IS.OUTER CASING for multi-cased wells)0 ble)
ER FIMMapIN4
GEOLOGIC EXPLORATION FROM I TO DIAMETER MATERIAL
Company Name MAY 1 2022 ft. I f, I I. I I
"16.INNER CASING OR TUBING(je6therrail closed-too`")
2.Well Construction Permit#: lawminun .rr'g UnAFROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County, 0.0 ft. 25.0 ft- 2.0 "" SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
'17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural DMunicipal/Public 25.0 ft' 40.0 ft' 2.0 in. .010 SCH 40 PVC
0 Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
01ndustrial/Commercial OResidential Water Supply(shared) -
,18.GROUT
0hrigation oWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 21.0 ft- PORTLAND BENTONrTE SLURRY
[EMonitoring ORecovery ft. ft.
Injection Well: ft. ft.
oAquifer Recharge 0 Groundwater Remediation
A9.SAND/GRAVEL PACK if app&able)
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
El Aquifer Test oStonnwater Drainage 23.0 f- 40.0 ft. 20-40 FINE SILICA SAND
OExperimental Technology oSubsidence Control ft. ft.
0 Geothermal(Closed Loop) OTracer .20.DRILLING LOG(attach additional sheets if necessary)
oGeothennal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/mck type,grain size,etc.)
0.0 ft' 5.0 ft- RED/ORANGE CLAY
4.Date Well(s)Completed: 04/28/22 Well ID# PZ-B 5.0 ft- 14.0 It- BROWN SILTY CLAY
5a.Well Location: 14.0 ft' 30.0 ft' BROWN MUDSTONE
SOUTH WAKE LANDFILL 30.0 ft- , 40.0 ft- GRAY ROCK
Facility/Owner Name Facility ID#(ifapplicable) 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-21.0-23.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification-
350 40' 53.11" N 780 50' 41.08" W A4V1 05/19/22
6.Is(are)the well(s): TPermanent or OTemporary 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: OYes 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 ivell construction information and explain the nature ofthe ofthis record has been provided to the well olvner.
repair under#21 remarla,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-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovei'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40.0 (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths ifelifferent(example-3@200'and 2@1001
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
Ifirater level is above casing,use"+
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
..GLD:Copy to DWR,CCPCUA
F ll_
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 2-7699- 6
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018