GW1-2022-07682_Well Construction - GW1_20220818

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR .14:.WATEWZONES.
Well Contractor Name FROM TO DESCRH'TION
ft. ft.
A - 3098 � a ft. ft.
NC Well Contractor Certification Number h b.-C.E i d� E-Ate+"
15.OUTER CASING:for;i Hjwcased wells OR'-LWER Map!]" icable.
GEOLOGIC EXPLORATION mom TO DIAMETER TxICIavESS MATERIAL
8 2Q22 ft. ft. in.
Company Name
16.INNER CASING'OR TUBING eoihermal:closed-loo
2.Well Construction Permit#• N1 CIt Fr'ja"'u'I P;nc.rC�ig UM FROM I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1.e.UIC,County,W.0.0 0e,erc.J 0.0 ft- 5.0 ft• 2.0 1O' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM�EE TO F
DIAMETER{ SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipaUPublic 5.0 ft' 15.0 ft' 2.0 in. .020 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) lS.GROUT
OhTI ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT MEPHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 4.0 fl- PORTLANDBENTONRE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge 25Groundwater Remediation
79:SAND/GRAYEUPACIC'if ti' 'liiiatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.5 ft- 15.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG'a"itach additional'sheewifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) FROM TO DESCRIPTION color,hardn soil/rock tyM grain size etc.
0.0 ft. 1.0 rt. BLACK TOPSOIL
4.Date Well(s)Completed: 06/08/22 Well ID# IW-7 1.0 ft. 14.0 ft. BROWN/RED SILTY CLAY
5a.Well Location: 14.0 It. 15.0 "' WHITE/GRAY SANDSTONE
WEAVER CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if applicable)
1209 DAWKINS STREET DURHAM 27707 ft. ft.
Physical Address,City,and Zip ft. ft.
DURHAM 21 REMARKS'_.I'``,a"
County Parcel Identification No.(PIN) BENTONITE SEAL-4.0-4.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-
350 58' 55.82" N 780 53' 58.50" W ' 06/22/22
6.Is(are)the well(s): OPermanent 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: ❑Yes or I9No 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill our known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#11 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 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 mmRUCTIONS
9.Total well depth below land surface: 15.0 (ft*)
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 6.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use o
11.Borehole diameter: 1 0.0/6.0 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018