GW1-2023-00747_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: k
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES } i
Well Contractor Name FROM TO DESCRIPTION
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A - 3098ft. ft.
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NC Well Contractor Certification Number (� 15,OUTER CASING for multi-cases wells OR LINER if a licable
GEOLOGIC EXPLORATION JAN 1 2023 FROM TO DIAMETER THICKNESS MATERIAL
rt. fr. in.
Company Name m
Inr��r;rl;;^1 O:�r. 3R0(1i,P't 16.INNER CASING OR TUBING eothermatclosed-loo
2.Well Construction Permit#: ryy Qi 30G FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.U1C,County,Slate,Variance,etc) 0.0 ft. 11.0 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 11.0 ft' 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
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 7.0 ft' PORTLANDBENTONITE SLURRY
(EMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifs licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 9.0 n- 21.0 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,soiltrock type,gmin sin,etc.
0.0 ft. 5.0 ft. BROWN SANDY CLAY
4.Date Well(s)Completed: 10/31/22 Well ID# MW-10 50 ft- 12.0 It- BROWN/TAN SILTY CLAY
5a.Well Location: 12.0 ft- 18.0 ft' BROWN PWR
GOODYEAR - 2506 18.0 It. 21.0 ft' GRAY PWR
Facility/Owner Name Facility ID#(if applicable) - 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-7.0-9.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
350 57' 34.18" N 770 49' 16.50" W 11/07/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the we/1(s)was(were)constructed in accordance frith
7.Is this a repair to an existing well: ❑Ves or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fit/out known well construction in%rntation and explain the nature gl'the ofthis record has been provided to the well owner.
repair under n21 remarks section or on the hack 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Ove?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.)
F'or multiple wells list all depths ifdwerent(example-3Gi)200'and 1 rci/00') 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 mates level is abuse coxing.use
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: 8.0 (in,)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open=Loon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department ofthe county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing,rover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,.NC 27699-1611
13a.Yield(gpm) Method of test:
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13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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