GW1-2022-05826_Well Construction - GW1_20220609

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
E
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 3098
ft. ft.
ft. ft. C
NC Well Contractor Certification Number
15:OUTER CASING for multi cased,,wells OR LINER if a Ilcable
FRO
GEOLOGIC EXPLORATION M TO DIAMETER THICKNESS MATERIAL
ft. I fr. � i in.
Company Name �
16.INNER CASING OR TUBING eothermA closed-loop)'
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well con.straction permits(i.e.WC,County.Stale,Variance,etc) 0•0 tt• 23.0 f- 2.01 in. SCH 40 PVC
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 23.0 ft' 43.0 fL 2.0 t"' 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 15.0 ft' PORTLAND,BENTONRE SLURRY
OMonitoring ❑Recovery ir. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20.0 tt• 43.0 tt• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I ft. i
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach'additiorial sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION coloq hardness soiUrock q rain sou,etc.)
0.0 rt• 10.0 rt• RED/ORANGE SANDY CLAY
4.Date Well(s)Completed: 05/19/22 Well ID# SSLF-PZ-4 10.0 rt. 30.0 tt• BROWN SILTY CLAY
5a.Well Location: 30.0 ft• 43.0 tf BROWN/GRAY SILTY CLAY
ALLEN STEAM STATION ft. ft. FIE: p r
Facility/Owner Name Facility ID#(if applicable) ft. ft.
253 PLANT ALLEN ROAD BELMONT 28012 ft. ft.
Physical Address,City,and Zip ft. ft. InjawraUcin
GASTON 21.REMARKS''' QJAQG
Wit; Rlt
County Parcel Identification No.(PIN) BENTONITE SEAL- 15.0-20.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***PIEZOMETER***
(if well field,one latflong is sufficient) 22.Certification:
350 11' 15.83" N 810 00' 38.65" W 05/23/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this furor,1 hereby certijy that theivell(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
If this is a repair,fill out known well 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(Laving the same You may use the back of this page toy provide additional well construction info
construction,only I GW-I 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: 43.0 (ft
For multiple wells list all depths ifdoerent(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: 25.0 (ft) 24a. For All Wells: Original form I Division of Water Resources (DWR),
lfwater level is above casing,use'-" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
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(]00,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: it Perm Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
N
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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