GW1-2021-03235_Well Construction - GW1_20210624

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
t
Lawrence D. O 14-WATERZbNES' . .
pPer FROM TO DESCRIPTION
Well Contractor Name
NC3322-A
NC Well Contractor Certification Number 15:OUTER CASING for mult'Cased tvelt's"OAi'INNER tfa"iicabie.. d _•
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
;,;16:ANNER CASING OR TUBt(1G eulheitrial'eto"sell laa"
Company Name
WM0501436 FROM TO DIAMETER; THICKNESS MATERIAL
2.Well Construction Permit#: p tt• 15 ft. 1 In. sch 40 PVC
List all applicable well construction permits(i.e.C'ounty,State,Variance,etc.)
ft. fL !in.
3.Well Use check well use):
Water Supply Well: FROM TO DIAMETER 'SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 15 ft' 25 ft' 1 in. 1.010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(Shared) FROMR��� TO f MATERLILI _ EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 3 ft. cement grout pour
Non-Water Supply Well: 3 ft. 14 ft. bentonite pour
2Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ,19:=SANDlGRAVEI PACK;ifs lic8til ... ..,.. i - ._ .�
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO ft MATERIAL EMPLACEMENT METHOD
it
❑Aquifer Test ❑Stormwater Drainage 14 25 No 1 sand Prepack,pour
ft. ft.
❑Experimental Technology ❑Subsidence Control ,
'420 D7ZILLIN0I:ifr7G=attach aillthotial necessary.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,wi6rock is e,gmin sin etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 25 ft. silty,clayey sand
ft.
4.Date Well(s)Completed:
5/13/2021 MW-7 tt.
it. ft.
5.Well Location: ft. ft.
Carriage House Cleaners DSCA92-0051 tt. ft. 02
Facility/Owner Name Facility ID#(if applicable)
ft. rt.
537 Plaza Circle, Raleigh ft. it. ra
Inform
Physical Address,City,and Zip
Wake 1711513109
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification-
(ifwell field,one latllong is sufficient) nrsy­ecyws eow'
N
35.70372 N -78.61118 W pp m=lzwrence Opper,o=RegionalProbi g
Lawrence O er`` A_;;"@, ign.orobm9raml,_us sm2o21
Signature of Certified Well Contractor Date
6.is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the srell(s)it-as(were)constructed in accordance
with 1 SA NCAC•02C.0100 or 15.4 NCAC 02C.0200 HIM Construction Standards•and that
7.Is this a repair to an existing well: ❑Yes or END copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
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, it can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli ferent(exmnple-3@ja 200'and 2C100') construction to the following:
10.Static water level below top of casing:
18 approx Division of Water Quality,Information Processing Unit,
(ft.)
If water level is above casing,use"i-" 1617 Mail Service Cent`er Raleigh,NC 27699-1617
11.Borehole diameter: 2.25 (in.) 24b.For Infection Wells: In additio tlo 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: direct-push construction to the following: i¢
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground,Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount completion of well construction to the county,health department of the county
where constructed. ( i
k
Form G W-I North Carolina Department of Environment and Natural Resources-Division of W ater Quality Revised Jan.2013