GW1-2022-07684_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
?^ g�
A - . ��5���"4� fr. ft. 4
NC Well Contractor Certification Number "�" "� I5.OUTERSGASING formulH cased wells,OR.LINER if a licable
GEOLOGIC EXPLORATION l S 202 FROM TO DIAMETER THIC[flVFSS MATERIAL
ft. fL in.
Company Name
^�P.^LJ r�4�LJrrt 16:,INNER CASING ORbTUBING�"eotherma`Itlosed-too.
2.Well Construction Permit FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,9t i* rtance,etc.) 0.0 ft• 5.0 ft 2.0 1°' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 5.0 "' 15.0 ft. 2.0 1n' .020 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 77ii7EiNT, ;
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 4.0 fL PORTLANDSENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: tt. ft.
❑Aquifer Recharge OGroundwater Remediation
'19.SAND/GRAVEL PACK'if a` lieiitile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
El Aquifer Test ❑StormwaterDrainage 4.5 n- 15.0 1` 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer `20.rDRMLING'LOG attach""additionalsheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnes soil/rock type,grain size etc.
0.0 It. 1.0 ft. BLACK TOPSOIL
4.Date Well(s)Completed: 06/10/22 Well ID# IW-5 1.0 ft• 8.0 tL RED/ORANGE CLAY
5a.Well Location: 8.0 ff 10.0 tf BROWN MUDSTONE
WEAVER CLEANERS 10.0 ft- 15.0 It. WHITE SANDSTONE
Facility/Owner Name Facility ID#(if applicable) ft. 'rt: - ---
1209 DAWKINS STREET DURHAM 27707 ft. ft.
Physical Address,City,and Zip ft. ft.
DURHAM 2E REMARKS--
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 latAong 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 ❑Temporary 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 MNo 15A NCAC 02C.0100 or ISA 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 having the same You may use the back of this page'to provide additional well construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15.0 (ft)
For multiple wells list all depths ifdifferent(example-3 200'and 1@I00) Submit this GW-1 within 30 days of well completion per the following:
6.0 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
Ifsvater level is above casing,use
11.Borehole diameter: 10.0/6.0 (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 Su I 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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