GW1-2021-03369_Well Construction - GW1_20210603

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER:ZONES
Justin Radford o �R� ' FROM TO DESCRIPTION
Well Contractor Name 30 ft' 35 ft• brown silt
3270 A ft. ft.
t'
NC Well Contractor Certification Number tt•'N J 202 15.OUTER CASING formulh-caseihwells OR L1NER 3f a lieable
Geological Resources, In �Ie�C'ro���slr�g 19�t1Z FROM ft• TO ft. DIAMETER TT.THICKNESS MATERIAL
it 3 n
Company Name d1C T�$J Fn ;16.INNER CASING OR TUBING"'eothermatclosed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 15 ft. 2° in. sch 40 PVC
List all applicable well permits(i.e.County,Stale, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN I% �
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft• 35 ft• 2 in 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 'a 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 10 `L Concrete Pour
Non-Water Supply Well:
2Monitoring ❑Recovery 10 ft• 13 ft• Bentonite Pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation "19.SAND/GRAYELPACK if applieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 15 ft• 35 ft• 'Sand Pour
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 15 e. 'Grey fine sand (rock screening)
02/16/2021 GMW-1 15 ft• 25 ft• Orange clayey sand
4.Date Well(s)Completed: Well 1D#
25 ft• 35 ft• Brown silt
5a..Well Location:
Star Mart 244 Five Points 0-000006218
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1641 Glenwood Avenue, Raleigh, NC
Physical Address,City,and Zip 21.REMARKS
Wake 1704-47-8493 wet at 30 feet
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
35.803241 N 78.646246 W `0}C�=/D� 02/17/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under'-'21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 35 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iJ different(example-3@a 2000'and 2 rd100') construction to the following:
10.Static water level below top of casing: 27.84 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
k
11.Borehole diameter:.611 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Solid flight auger 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&Injection Wells:.
;
Also submit one copy of this form;within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013