GW1-2023-00739_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
A - 3098 ft. a.
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-tea i.z.
NC Well Contractor Certification Number �� 15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION JAN 1 2023 FROM TO DIAMETER THICKNESS MATERIAL
ft. fr. i in.
Company Name <
lflrOi%P,;.:^-71 f;;•3 ;-i ( F36.INNER CASING OR TUBING eothermal closed-loci
2.Well Construction Permit#: D-V Q;0G FROM I TO I DIAMETER I THICKNESS I MATERIAL
list all applicable,cell construction permits(i.e.U/C,County,State,Variance,etc.) 0.0 ft' 1 18.0 ft- 1 2.0 "' I SCH 40 PVC
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tt. ft. in-18.0 28.0 2.0 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wel Is> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 12.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery R. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 16.0 it 28.0 ft' 1 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control fr. tr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiltrack e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 fr 1.0 ft' BLACK TOPSOIL
4.Date Well(s)Completed: 08/19/22 Well ID# IW-27 B 1.0 ft. 8.0 ft. GRAY CLAY
5a.Well Location: 8.0 ir' 10.0 ir' GRAY PWR
EATON CORPORATION 10.0 ft• 28.0 ft. GRAY ROCK
Facility/Owner Name Facility ID#(if applicable) f1. ft. I
2564 DURHAM ROAD ROXBORO 27573 ir. ft.
Physical Address,City,and Zip ft. ft.
PERSON 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 12.0-16.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
360 21' 32.60" N 780 59' 04.59" W �`�"� 09/01/22
6.Is(are)the well(s): (EPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing this form,l hereby c•ertifj,that the rrell(r)was(sere)c•onstrttc•ted in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.11l0(l or l5A NCAC 02C.0200 Well Constrac•tion Standards anti that a cnpt•
tjthi.v is a repair,till out known well construction tnlbrmation and erplain the more of the a/7his record has been provided to the well owner.
repair under=21 remarks section or on the hack of this fbrnn.
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 I 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: 28.0 (ftJ
For multiple wells list all depths if'dijlerent(example-3 a 200'and 1@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 11.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
I/,rater level is abort casing,use"+" Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
6,0 24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
11.Borehole diameter. (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
j
12.Well construction method: AIR 24c.For Water Supply and OpenLoop 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(gpm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018