GW1--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