GW1-2023-00746_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
JOHNNY BURR :14.WATER ZONES C
FROM TO DESCRIPTION
Well Contractor Name ¢ ( ft. ft. ,
NC Well Contractor Certification Number J A N 1 2023 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. I ft.
Company Name ifli�:.+ti': ,`L'1 r't• -�r- t
J"0 v a-1J'G 16.INNER CASING OR TUBING geothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 12.0 f- 2.0 i in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply WelkFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 12.0 ft' 22.0 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
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 7.0 ft' PORTLANDBENTONITE SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well:
rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 10.0 fr• 22.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. rt.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soiUmck tyM grain size,etc.
0.0 ft- 5.0 ft• BROWN SANDY CLAY
4.Date Well(s)Completed: 11/O1/22 Well ID# MW-11 5.0 ft- 12.0 ft. BROWNITAN SILTY CLAY
5a.Well Location: 12.0 ft. 18.0 ft' BROWN PWR
GO_ODYEAR - 2506 18.0 fr. 220 ft- GRAY PWR
Facility/Owner Name Facility ID#(ifapplicable) ft. -
2088 STONE ROSE DRIVE ROCKY MOUNT 27804 rt. ft.
Physical Address,City,and Zip
ft. I ft.
NASH 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-7.0-10.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lit/long is sufficient) 22.Certification:
350 57' 34.18" N 770 49' 16.501, W 11/07/22
6.Is(are)the well(s)• (EPermanent or ❑Temporary Signature ofCenified Well Contractor Date
By signing this form,l hereby certify ihal the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15N6 15A NCAC 01C.0/00 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
q'this is a repair,fit/out known well construction information and explain the nature of the of this record has been provided to the 00 owner.
repair under 921 remarks section or on the back of dtis Jornr.
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'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 22.0 (ft.)
Por multiple we//s list all depths iif'dijj�rent(example-3Gd200'and 1 cGd l00') Submit this GW-1 within 30 days;of well completion per the following:
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
1/lraier level is obore casing,use"i
I
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy t6 DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER 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 roducin over 100 000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a,field(gpm) Method of test:
i
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018