GW1-2022-07925_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR '14 WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098
ft. ft. �
NC Well Contractor Certification Number '15.OUTER"CASING for multi-cased wells O11,INER ifs 'licabli
GEOLOGIC EXPLORATION FROM TD DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING 'eotbermal closed-loop)
2.Well Construction Permit#: W M0301199 FROM TO DIAMETER THICKNESS MATERLAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft- 25.0 It. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: M SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 It' 40.0 It• 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) - 8.'GROUT
❑IrrI ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 20.0 it. PORTLANDBENTOMTE SLURRY
[EMonitoring ❑Recovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifs licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage 23.0 ft- 40.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I FROM I To DESCRIPTION color,hmilness,soiltrock type,gimin size,etc.
0.0 ft- 4.0 ft- RED/ORANGE TOPSOIL
4.Date Well(s)Completed: 06/15/22 Well ID# MW-6 4.0 ft- 16.0 ft. BROWN SILTY CLAY
5a.Well Location: 16.0 Ir• 23.0 It' GRAY/BROWN SILTY CLAY
JAYS ONE HOUR CLEANERS 23.0 ft 40.0 fl- GRAY SILTY CLAY
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1803 NORTH MAIN STREET KANNAPOLIS 28081 It• ft.
Physical Address,City,and Zip ft. ft.
ROWAN 21.REMARKS
County Parcel IdentificationNo.4PIN) BENTONITESE ,ff) . FEE
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: p I� ' 2027
350 31' 11.56" N 800 36' 49.00" W `6u-1
Irf^•sn-,ia4ic��ru;:�:����I�22
6.Is(are)the well(s): 251'ermanent or ❑Temporary Signature of Certified Well Contractor DD+JQ,iBOGE to
by signing this form,I hereby cerlify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or (MNo 15A A'CAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under 921 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 Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40.0 (ft.
For multiple wells list all depths ifdiJferent(example-3 rev 200'and 2 rev 100') ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 26.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
/fwater level is shore casing,use +" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loon Geothermal Return Yells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county in
environmental health department of the county where stalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingfover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 2 7699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018