GW1-2022-07646_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14:WATEWZONES ._
Well Contractor Name FROM TO I DESCRIPTION
ft. ft.
A - 3098
ft. ft.
NC Well Contractor Certification Number +� s+�
'�It e15.OUTER CASING'fog Tu tt-casediv4'ells;rOR;L'INERi if a"'Hicable i`•
GEOLOGIC EXPLORATION �^�" 0 8 FROM TO DIAMETER THICKNESS MATERIAL
R. fL in.
Company Name
AUG 1 8 2022 MANNERCASINGORi1[JRING' eoltieimal losedloo"� ,=
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(r.e.C� y ?j�ggr��tra7ir&rS A'T 0.0 ft- 53.0 ft- 2.0 In. SCH 40 PVC
3.Well Use(check well use): OA:l015OG ft. ft. in.
Water Supply Well: 17.SCREEN -
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 53.0 ft. 63.0 "' 2.0 1°' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) , GROUT=' ' ]....- .';
❑hTi ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 40.0 ft' PORTIANDBENTONRE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19iSAND/GRAVEL-PAC K ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 50.0 rt. 63.0 I'L 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
[]Geothermal(Closed Loop) ❑Tracer ti20.DRILLING LOG ettaeli'edditidnal sheits ifnecessa' ,'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn sou/mckriM grain size,eta
0.0 rt. 63.0 It. BROWN PWR
4.Date Well(s)Completed: 07/13/22 Well ID# MW-13 ft. ft.
Sa.Well Location:
ft. ft.
NCDOT MAINTENANCE YARD ft. ft.
Facility/Owner Name Facility ID#(if applicable) It. ft.
5426 NC - 141 MARBLE 28905 ft. ft.
Physical Address,City,and Zip ft. ft.
CHEROKEE 1LREMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-40.0-50.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 17-
(ifwell field,one IatAong is sufficient) 22.Certification:
350 08' 17.81" N 830 55' 31.71" W 07/29/22
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certI&that the well(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo /5A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fil/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 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
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: 63.0 (ft)
For multiple wells list all depths ifdifferent(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: 27.0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+' Information Processing Unit,1617 i MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.0 (in,) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(RJC)
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'00,000 GE
D:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,161 I MSC,Raleigh,NC 27699-16 1 1
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13b.Disinfection type: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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