GW1-2023-00773_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.A - 3098 I ,
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a 8icable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-lob
2.Well Construction Permit#: FROM I TO I DIAMETER FTHICKNESS I MATERIAL
List all applicable well construction pernths(i.e.UIC.County,State,Variance.etc.) 0.0 ft. - 23.0 ft. 2.0 '"' SCH 40 PVC
3.Well Use(check well use): ft. fr.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 23.0 ft' 43.0 f" 2.0 in' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl ation ❑Wel Is>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 10.0 ft. PORTLANDBENTONITE SLURRY
Monitoring ❑Recovery fr. ft.
Injection Well: ,Y 1• y1
❑Aquifer Recharge ❑Groundwater�etngWgdcln-'LM°
19.SAND/GRAVEL PACK if a i licable
❑Aquifer Storage and Recovery ❑Salinity Barrier I C +F OM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainagCA� 1 r 21.0 ft• 43.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control 7,;^.:r% %') ?i. fr.
r�
ICtivSf:=3Y.;;;l i �
❑Geothermal(Closed Loop) ❑Tracer t :'-jro": ` 20.DRILLING LOG attach additional sheets ifnecessa
FROM TO DESCRIPTION color,hairiness,soil/rack e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 70 It. RED/BROWN PWR
4.Date Well(s)Completed: 1 O/27/22 Well ID# MW_1 7.0 ft' 40.0 ft• GRAY PWR
5a.Well Location: 40.0 ft• 43.0 ft' BROWN ROCK
RESIDENCE ft. fr.
Facility/Owner Name Facility lD9(ifapplicable)
4208 LAKE CLIFF DRIVE CLEMMONS 27012
Physical Address,City,and Zip
ft. ft.
FO RSYTH 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 10.0-21.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one la/long is sufficient) 22.Certification:
360 01' 30.51" N 800 24' 46.89" W 11/02/22
6.Is(are)the well(s): 291'ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this•form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!9No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/J'this is a repair,Jill out known well construction inJbrnration and explain the nature of the ofthis record has been provided to the ire/l owner.
repair under 921 remarks section or on the back ofthis 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 1 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: 43.0 (ft.)
Far aulliple wells list all depths ifdiereni(exannple-3 a 200'and 2 rci 100') Submit this GW-1 within 30 days of well completion per the following:
30•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
/J'wnter level is above casing,use"+"
11.Borehole diameter: 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: 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018