GW1-2023-00745_Well Construction - GW1_20230113

I
l .
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well Contractor Information:
E
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 3098 ft. ft.
ft. ft.
NC Well Contractor Certification Number15.
GEOLOGIC EXPLORATION FROM ERCASIIvc"formnld-c ET Wens ORLINER fEa licable
�,; �, �:>��>/ � '^ F" FROM TO DIAMETER THICKNESS MATERIAL
�{ ft. ft.
Company Name Jl�IV J
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit# , t t FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,lt�n( Stp7e'"Garrancetc:J' J 0.0 ft- 8 0 ft. 2.0 in SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8.0 ft' 18.0 f' 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
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 4.0 ft' PORTLANDSENTONITE SLURRY
OMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 6.0 ft- 18.0 fL 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) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
0.0 ft- 6.0 ft• RED/ORANGE SANDY CLAY
4.Date Well(s)Completed: 10/31/22 Well ID# MW-12 6.0 ft• 10.0 f` BROWN SILTY CLAY
5a.Well Location: 10.0 ff 16.0 ff BROWN PWR
GOODYEAR - 2506 16.0 ft- 18.0 fL GRAY PWR
Facility/Owner Name Facility 1139(ifapplicable) ft. ft. -
2088 STONE ROSE DRIVE ROCKY MOUNT 27804 ft. ft.
Physical Address,City,and Zip ft. ft.
NASH 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-4.0-6.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 57' 34.18" Iv 77° 49' 16.50" W 11/07/22
6.Is(are)the well(s): 2flPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance Irish
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
U this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the u;ell owner.
repair under 921 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS -
9.Total well depth below land surface: 18.0 (ft.)
For multiple wells list a//depths ifdii ferent(example-3 c@i 200'and 2 c@i 100') Submit this GW-1 within 30 days of well completion per the following:
$•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 easing,use
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 OpeniLoop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depart i me nt of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinQ'over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh i ,NC 27699-1611
I
13b.Disinfection type: Amount:
it
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
i