GW1-2023-00983_Well Construction - GW1_20230118

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
tt. ft.
A - 3098
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING Tor 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(geothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) 0.0 It. 6.0 rt. 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 6.0 ft' 16.0 ft' 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) Ir. ft. in.
Olndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD B AMOUNT
Non-Water Supply Well: 0.0 ft. 3,0 ft' PORTLANDBENTONUE SLURRY
nMonitoring ❑Recovery ft. ft.
Injection Well: tr. 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 ❑Stonrnvater Drainage 4.0 ft. 16.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. fr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2] Remarks)
0.0 It. 1.0 It- BLACK TOPSOIL
4.Date Well(s)Completed: 10/24/22 Well ID# MW-4 1.0 rL 16.0 ft• l.--%,,Ro Z V.tL I
Sa.Well Location:
ft. ft. f II... LZ e
GRAHAM COUNTY LANDFILL ft. fr. ^ a
2023
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
400 SNOWBIRD ROAD ROBBINSVILLE 28771 ft. ft. Vrl.c
Physical Address,City,and Zip ft. ft. 'c •""
GRAHAM 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL-3.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 18' 53.39" N 830 48' 53.12" W 11/07/22
6.Is(are)the well(s)• IMPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the trcH(s)uns(wore)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1J'1his is a repair,fill out known well construction information and explain the nature of the oJ7hts record has been provided to the well owner.
repair under#21 remarks section or on the back 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-1 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: 16.0 (ft.)
Por,nuhiple,re/ls list all depths ifdifJcrett(example-3 ut 200'and 2 r(�r 100') Submit this GW-1 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),
1f water level is above casing,use"+•• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b. For injection Wells: Copy to 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 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018