GW1-2022-08713_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR :44:WATER-,Z0NEs:
Well Contractor Name FROM TO I DESCRIPTION
ft. ft.
A - 3098 ft. it.
NC Well Contractor Certification Number 15 OUTER CASING`formulti cased"'wells OA LIPiER if a`7iceble
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. & in
Company Name
16:=INNER'CASING OR TUBING, eothermal'closed-466
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0,0 ft. 13.0 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 ❑Municipalftblic 13.0 ft' 23.0 ft' 2.0 'n .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) s118:„GROUT.`:%
❑Irri ation []Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 7.0 IL PORTLANDBENTONITE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if ii livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 11.0 ft- 23.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed LOOP) ❑Ttdeei 20.=DRILLING LOG`attacH additional sheets'ifnecesdi` ".
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 it' 4.0 ft- ORANGE SANDY CLAY
4.Date Well(s)Completed: 05/04/22 Well ID# PZ-G 4.0 It- 8.0 ft- WHITE/GRAY SANDSTONE
5a.Well Location: 8.0 ft' 23.0 ft' GRAY ROCK
DAVIDSON COUNTY LANDFILL ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1242 OLD US HIGHWAY 29 THOMASVILLE 27360 ft. ft.
Physical Address,City,and Zip ft. ft.
DAVIDSON 21..REMARxs s=�
County Parcel Identification No.(PIN) BENTONIfE SEAL-7.0-11.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 51' 11.62" N 800 10' 34.66" W A4e f) 05/19/22
6.Is(are)the well(s): [EPermanent or .❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifihis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has beenprovided to the well owner. DJ
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 con�s"ctign infospy�
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional p igesl 114,ess
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 23.0 (ft.)
For multiple wells list all depths ifeli/jerent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 12.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifivater level is above casing,use"+^ Information Processing Unit,1617 MSC,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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1
(gPm) 611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018