GW1-2023-02748_Well Construction - GW1_20230417

i
( Pnnt Foriil
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Onlv:
1.Well Contractor Information:
Mike Tynan _14:WATERZONIS
Well Contractor Name FROM TO DESCRIPTION
2725-A 19 ft- 28.5 ft. silty sand
ft. ft. j i
NC Well Contractor Certification Number
t:15.`OUTER CASING(Foe oiulti-cased'ivells'OR`LINER il'a° licame
ETFROM TO DIAMETER THICKNESS 1111WRLIL
ft. ft. in.
Company Name
16.,INNER CASING OR-TUBING(eatlie`rma d l osed too i I
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale, l'ariance,etc.) 0 f- 13.5 ft. 2 in. Sch40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well; FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]Agricultural Agricultural nMunicipal/Public 13.5 ft. 28.5 ft. 2 in. 0.010 Sch40 JPVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) fL ft•
hidustrial/Commercial El'Residential Water Supply(shared) 18.GROU1
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irri ation IJNT
Non-Water Supply Well: 0 ft- 3 ft. concrete pour
X.Monitoring EIRecovery 3 ft. 11 ft. bentonite our through augers
Injection Well: - - - - -- pour- -- g- g-- - - -� -
'ft. ft.
Aquifer Recharge Groundwater Remediation
19fSi41YD/GRAM:PACK(if:a licAtilc
Aquifer Storage and Recovery [3 Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENTMETHOD
(Aquifer Test EIStormwater Drainage 11 ft. 28.5 ft. #2 silica sand pour through augers
:]Experimental Technology OSubsidence Control fc. ft.
Geothermal(Closed Loop) Tracer '20.+DRILL[NG LOG:attachadditional:'sheets ifnecessar
- FROM TO DESCRIPTION color,hardness,soittroek e, rain size,etc.
_;Geothermal(Heating/Cooling Return) ;Other(explain under 421 Remarks) ft. R.
See consultant's log
4.Date Well(s)Completed:04/03/2023 Well ID# MW 1 ft. &
5a.Well Location: ft. ft.
Fuquay's Texaco r�� _. '
Facility/Owner Name Facility lD#(ifapplicable) ft. ft.
424 S. Anthony St, Burlington 27215 ft. ft
Physical Address,City,and Zip ft. ft.
Alamance iI:RENIARILS i,is,'' �{�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36 04 58.29 N -79 25 44.58 W
04/09/2023
6.Is(are)the well(s)2]Permanent or EITemporary Signature of Cc epd Well Contractor Date
By signing this fann,I hereby certify that the well(s)tras(were)constructed in accordance
7.Is this a repair to an existing well Yes or@No with 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 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 site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 28.5 ft.
P ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple irells list all depths(f different(example-3@ 200'and 1 a 100') construction to the following:
10.Static water level below top of casing: 19 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,Use 11,11 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8•5 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
auger above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply&Iniection.Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I