GW1-2023-00960_Well Construction - GW1_20230118

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name A - 3098 ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) 0.0 ft. 5.0 ft• 2.0 in SCH 40 PVC
3.Well Use(check well use): ft. ft. in,
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft' 15.0 ft' 2.0 1°' 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl atioll ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery rt. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft 15.0 H' 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 421 Remarks) FROM TO DESCRIPTION(color-,hardness,soilhwk type,grain sin,etc.)
0.0 ft 0.5 ft GRAVEL
4.Date Well(s)Completed: 1 0/03/22 Well ID# MW-1 0.5 ft 14.0 11• BROWN SILTY CLAY
5a.Well Location: 14.0 ft- 15.0 ft- BROWN PWR
NCDOT BUCKEYE SHED ft. ft.
Facility/Owner Name Facility I D#(ifapplicable) ft. ft.
52 LAKESIDE DRIVE BAKERSVILLE 28705 ft. ft. JAN 1 9 202
Physical Address,City,and Zip ft. ft.
MITCHELL 21.REMARKS t1+ nt= ' ,I - �a r
County Parcel Identification No.(PiN)
BENTONITE SEAL-3.0-4.0 FEET ` t3`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifvvell field,one[at/long is sufficient) 22.Certification:
350 59' 55.83" N 820 09' 20.84" W ) `' 10/19/22
6.ls(are)the well(s): OPermanent or ❑Temporary Signature ofCettified Well Contractor Date
By signing this fornt,i hereby certJY that the u,el/(s)was(were)constructed in accordance uWth
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or i5A NC4C 02C.0200 Well Construction Slandardr and that a copy
l/7his iv a repair,fill out known ire/l consiruction iiiforntatioli and erplain the itaatre ofdte ofthis record has been provided to the well oirner.
repair under N21 remarkv section or on the back q/'this form.
23.Site diagram or additional well details:
S.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: 15.0 (ft.)
h,or nutltiple wells list at/depths 11diiJJerent(example-3 rev 200'and 2 rt 100) Submit this GW-i within 30 days of well completion per the following:
10.Static water level below top of casing: 6.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lJirater level is above casing,use"+" 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
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
13a.field(gpriT) Method of test: Perin it 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