GW1-2022-07940_Well Construction - GW1_20220823

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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
'I5.OUTER CASING. for multi-cased wells OR LINER'ifs "licable
GEOLOGIC EXPLORATION FROM TO DIAMETER TxICIOVESS MATERIAL
ft. ft. j (io.
Company Name
16.INNER CASING OR TUBING cothermal closed-loci'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 IL 6.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN `
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 6.0 tt. 21.0 ft 2.0 in. 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 3.0 ft' PORTtANDaENTONITE SLURRY
P3Monitoring ❑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 EMPLACEMENrMErHOD
❑Aquifer Test ❑Stormwater Drainage 5.0 tt 21.0 ft 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if a 4
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnes soil/rock tyM grain size etc.
0.0 tt• 2.0 1" GRAVEL
4.Date Well(s)Completed: 05/25/22 well ID# MW-12 20 ft. 190 ft. BROWN PWR
Sa.Well Location: 19.0 ft' 21.0 ft' GRAY ROCK
VANCE COUNTY LANDFILL ft. ft.
Fueility/Owner Name Facility ID#(if applicable) ft. ft.
3181 NC - 39 HENDERSON 27537 ft. ft.
Physical Address,City,and Zip
rt. ft.
VANCE -21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-5.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattiong is sufficient) 22.Certification:
360 22' 06.64" N 780 25' 11.48" P-dr/ .644-1
w --� „ © 1 22
6.Is(are)the well(s): EPermanent or ❑Temporary Signature of Certified Well Contractor Da
fr-
By signing this farm,I hereby certify that the well(s)fivp�tveFb)ctyts�n accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 WW��FFII onst4,,)Cc n ds and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ojthis record has been provided to the ivell owner.
repair under#21 remarks section or on the back of this form. n¢�- r__saCa p r.-Cw,,Vr_g Unit
23.Site diagram or additional well aetalfs: D1AJQ/B0G
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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 21.0 (ft.)
For multiple wells list a//depths ifdifferent(example-3@200'and 2 rr 100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 10.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit,1617 IMSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0/6.0 (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
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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 Resource) Revised 6-6-2018