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HomeMy WebLinkAboutGW1--03010_Well Construction - GW1_20230306 WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: JOHNNY BURR 14.WATER ZONES i Well Contractor Name FROM TO DESCRIPTION ft. ft. A - 3098 fr. fr. NC Well Contractor Certification Number 15.OUTER CASING for.multi-cased wells OR LINER if a livable GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL rr. rr. in. Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) 0.0 ft. 15.0 ft. 2.0 1n. SCH 40 PVC 3.Well Use(check well use): ft. ft. in. 17.SCREEN Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ❑Agricultural ❑Municipal/Public 15.0 it- 25.0 ft' 2:0 in. .010 SCH 40 PVC ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0.0 rr. 9 0 ft' PORTLAND BENTONITE SLURRY [EMonitoring El Recovery Injection Well: ft. ft. ❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD ❑Aquifer Test ❑StormwaterDrainage 13.0 fr• 25.0 ft' 20-40 FINE SILICA SAND ❑Experimental Technology ❑Subsidence Control ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,e1c.) ❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder#21 Remarks) 0.0 fr• 1.0 tt CONCRETE 4.Date Well(s)Completed: 01/24/23 Well ID# MW-1 1.0 ft• 6.0 ft TAN/BROWN CLAY 5a.Well Location: 6.0 fr' 25.0 tt' BROW_N/TAN ROCK WHAT A WASH LAUNDRY ft. ft. Facility/Owner Name Facility ID#(if applicable) ft. ft. - 901 EAST 3RD STREET SILER CITY 27344 ft. ft. 1 LUZ3 Physical Address,City,and Zip ft. ft. CHATHAM 21.REMARKS County Parcel Identification No.(PIN) BENTONITE SEAL-9.0-13.0 FEET L- 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one]at/long is sufficient) 22.Certification: Q 350 43' 49.28" N 790 27' 05.45" w � 02/10/23 6.Is(are)the well(s): [EPermanent or ❑Temporary Signature ofCerified Well Contractor Date By signing this•form,I hereby certify that the well(s)was(here)constructed in accordance with 7.Is this a repair to an existing well: ❑Yes or ONo i5A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and t/rat a copy Ifihis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well ou ner. 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 Over'in Remarks Box).You may also attach additional pages if necessary. drilled: 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 25.0 (ft.) nor umhiple,rills list all depths ry'di fireni(example-3�00'and 2@100')10. Submit this GW-1 within 30 days of well completion per the following: 15.0 24a. For All Wells: Original form to Division of Water Resources (DWR), /firater level it above casing,use"+"Static water level below top of casing: (ft.) 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.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611 13b.Disinfection type: Amount: Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018