GW1-2022-07685_Well Construction - GW1_20220818

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. j
A - 3098 ft. ft.
NC Well Contractor Certification Number - v
i �'' � 15t;OUTER CASING'focmiilti-cased.wells OR<LINER if a' licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
tr. tr. j in.
Company Name J _
16.1NNER CASING=OR:T--IJRING 'eotheinial closed-lob
2.Well Construction Permit#: - �� p.,,,,,�„e;,,, FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UI , ounty, j,4rt V i g 1c.) 0.0 ft. 5.0 ft. 2.0 1° SCH 40 PVC
3.Well Use(check well use): H8 tSVI ir' tc t°
Water Supply Well: ,FROM
PPy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 It- 15.0 it' 2.0 1 ' 1 .020 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. g, 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. 4.0 ft. PORTL4ND8ENTONRE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge 15Groundwater Remediation
lA SAND/GRAVEL PACK ita licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.5 ft. 15.0 rL 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING.LOG.attach addidodal''sheits ifrieet§sa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock qpe,grain size,etc.
0.0 ft. 1.0 ft. BLACK TOPSOIL
4.Date Well(s)Completed: 06/08/22 Well ID# IW-8 1.0 ft. 10.0 ft. RED/ORANGE CLAY
5a.Well Location: 10.0 ft' 15.0 ft' BROWN MUDSTONE
WEAVER CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. k.
1209 DAWKINS STREET DURHAM 27707 rt. tr
Physical Address,City,and Zip ft. ft.
D U R H AM 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-4.0-4.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35° 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 Dace
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 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis 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 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 INSTRUCTIONS
9.Total well depth below land surface: 15.0 (ft.)
For multiple wells list all depths ifdi(jerent(example-3 r@200'and 2@100) 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
Ifwater level is above casing,use
10.0/6.0 24b.For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/AIR 24c.For Water Supply and Open- oo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department o the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin 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:
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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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