GW1-2022-07689_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.
A - 3098 ft. ft.
NC Well Contractor Certification Number Fk f�M i s v 15.OUTER CASING for multi cased wells'-0R<LINER if a "licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. i".
Company Name
16:]NNER,CASINGORT ING "eothermitclwed-loo'
2.Well Construction Permit#: 7-LIC '. Unf FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. a&a ouniy� ViSge,etc.) 0.0 ft. 5.0 rt 2.0 1O SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.=SCREEN
PPY FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 It' 15.0 It' 2.0 r"' 1 .020 SCH 40 PVC
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 15.GROUT
❑liTl ation ❑Wells>100000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 4.0 fL PORTLANDBENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if a Ocable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.5 ft- 15.0 It. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING•IAG tattich additidnal.iheets'if necessti
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn soil/mck IyM grain size,etc.
0.0 it. 1.0 ft BLACK TOPSOIL
4.Date Well(s)Completed: 06/10/22 Well ID# IW-11 1.0 ft. 6.0 1- RED/ORANGE CLAY
59.Well Location: 6.0 ft' 12.0 ft' BROWN MUDSTONE
WEAVER CLEANERS 12.0 ft- 15.0 ft- WHITE SANDSTONE
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1209 DAWKINS STREET DURHAM 27707 ft. ft.
Physical Address,City,and Zip ft. ft.
DURHAM 21.'REMARKS",;
County Parcel Identification No.(PIN) BENTONIfE SEAL-4.0-4.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient) 22.Certification:
35° 58' 55.82" N 78° 53' S8.50" W 06/22/22
6.Is(are)the well(s): 091'ermanent or ❑Temporary Signature of Certified well Contractor Date
By signing this form,I hereby terrify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [5No 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 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 tfdifferent(example-3@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
If water 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-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 Revised 6-6-2018
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