GW1-2023-00804_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name � ��-';1-,..%, I'
FROM TO DESCRIPTION
A - 3098 4
NC Well Contractor Certification Number V
��!J 15.OUTER CASING for multi-cased wells)OR LINER if a able'
GEOLOGIC EXPLORATION JAU FROM TO DIAMETER THICKNESS MATERIAL
ft. I ft. I in.
Company Name .7 --:"
-„�.• ?Cy 16.INNER CASING OR TUBING 'eothermal closed-loon)
2.Well Construction Permit#: � .''k'� FROM I TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft. 4.0 ft. 2.0 '"• SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 4.0 ft' 14.0 ft' 2.0 �"' .010 SCH 40 PVC
❑Geothermal(Heating/CoolingSuppty) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01rrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2.0 ft. PORTLAND BENTONITE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a (licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 3.0 ft 14.0 B• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑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- 13.0 1- BROWN SILTY CLAY
4.Date Well(s)Completed: 10/04/22 Well ID# MW-4 13.0 ft- 14.0 ft- BROWN PWR
Sa.Well Location:
ft. ft.
NCDOT BUCKEYE SHED ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
52 LAKESIDE DRIVE BAKERSVILLE 28705
Physical Address,City,and Zip ft. ft.
MITCHELL 21.REMARKS
County Parcel identification No.(PIN) BENTONITE SEAL-2.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3SO 59' 55.83 N 820 09' 20.84" W ��� 10/19/22
6.Islam)the well(s): EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the Ire/l(s)it-as(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well 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 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: 14.0 (ft.)
1--or multiple wells list an depths q•difireni(example-3@200'and 2 rr 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: $'� (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
{/hater level is above casing use"4 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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 i24c.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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018