GW1-2021-03536_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
James Robertson 14.WATER ZONES
Well Contractor Name FROM TO ft DESCRIPTION
ft
4482 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multrcased ells OR LINER if a livable
Parratt-Wolff, Inc. FROM TO DIAMETER THICKNESS MATERIAL
n. ft. in.
Company Name
W 10501053 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
list all applicable well construction permit,(i.e.UK%Countyt.Stale.1%ariance,e1c.) ft. ft. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial El Residential Water Supply(shared) 18.GROUT
❑lrrl atlon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control H. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft. ft.
TO DESCRIPTION color,hardness,soiltmck type,gnin size,etc.)
4.Date Well(s)Completed: 5/4-5/6 2021 Well ID# IP-1 through IP-20 ft. ft,
5a.Well Location: R. ft. t
Former Garner Exxon/J&S Petro,LLC 0-0000005241 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1
1305 US 70 W, Garner, NC 27529 f° ft.
Physical Address,City,and Zip ft. ft. f0 fr+`jilQr'1 rocessilig
Wake 1701675103 21.REMARKS LJVV
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one[at/long is sufficient) 22.Certification:
35 42' 39" N 78 37' 22" W
h
6.Is(are)the well(s): ❑Permanent or (ITemporary S" amre ofCerted W I Connacror Date
By signing this./imnh,I herehv certi/6 that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 1.5A NCA'02C.0200 Well Construction Standards and that a copy
/J7his is a repair,Jill out known we/1 construction information and explain the nature of the of this record has been provided to the troll owner.
repair under=21 remarks.section or on the hack of this ornh.
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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:20 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 33 (ft.) Submit this GW-1 within 30 days of well completion per the following:
bbr muhiple wells list all depths if'dilPrent(example-3 a100'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: (fo Information Processing Unit; 1617',MSC.Raleigh,NC 27699-1617
1l water level is above casing,use"
11.Borehole diameter: 2 (in,) 24b. For Infection Wells:Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh;NC 27699-1636
12.Well construction method: direct push
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
Pen-nit Program, 1611 MSC.Raleigh.NC 27699-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018