GW1--03027_Well Construction - GW1_20230307

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ff a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. f[. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WM0501 537 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well consirucvion permits(i.e.UiC,County,Stare,Variance,etc.) 0.0 ft- 32.0 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 32.0 ft• 47.0 ft' 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr, ft. in•
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01rr1 ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 25.0 ft' PORTLANDBENTONITE SLURRY
[EMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 30.0 It- 47.0 ft• 20-40 FINE SILICA SAND
[]Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin sae,etc.)
0.0 It- 1.0 ft. BLACK TOPSOIL
4.Date Well(s)Completed: 02/03/23 Well ID# MW-BG 1.0 ft• 6.0 fL ORANGE/BROWN CLAY
5a.Well Location: 6.0 ff• 15.0 ft' BROWN PWR
VANCE COUNTY LANDFILL 15.0 ft• 47.0 ft• GRAYiROCK_
Facility/Owner Name Facility ID#(if applicable)
3181 NC 39 HENDERSON 27537 ft. ft.
,..
Physical Address,City,and Zip ft. ft. J
VANCE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-25.0-30.0 FEET-'`: ?
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
360 22' 06.84" N 78e 25' 10.52" W 02/10/23
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
lay signing this•form,i hereby certify that die irell(s)was(were)constructed in accordance whit
7.Is this a repair to an existing well: ❑Yes or [5No 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and chat a c•opi,
If ibis is a repair,fill out known well construction itiforniatiou and explain the nature of the of this record has been provided to the irel/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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (adcl'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 47.0 (ft.)
For nnthiple wells list all depths ifd &rent(example-3 tt 200'and 2 cr 100') Submit this GW-1 within 30 days of well completion per the following:
35.5 24a. For All Wells: Original form to Division of Water Resources (DWR),
lf'i j Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lralerlerel is above casing,use";"
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:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018