GW1-2021-06470_Well Construction - GW1_20211022

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Todd Muench 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3371 fL
ft. ft.
NC Well Contractor Certification Number
Inc. �75::OUTER CASING formulfi-cased'�rells OR-LINER`ifa- );cable' _
Parratt-Wolff, n FROM TO DIAMETER THICKNESS MATERIAL
ft. & in.
Company Name ;.16::INNER:CASING'OR,
W10501 O84 TUBING- eodtermil.clbsed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable sell c•onsiruclion perntirs(i.e. (Ilt',Coun(v,Stare, l'ariance,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: 17:-SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. R- in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) it.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irri atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery ft. ft.
Injection Well: tit. ft.
Aquifer Recharge Groundwater Remediation
49.'SAND/GRAVEL PACK if a chile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 3oDRiI:BING'EOG,atiac7isaddreonilslieeblit.""""
FROM TO DESCRIPTION color,hardness,soil/rock tyM
grain size,etc.
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) ft ft.
4.Date Well(s)Completed: 10/11/21 WellID#IP-29 - IP-32 ft. ft. c
5a.Well Location: ft. ft.
William Newton ft. fL 11
Facility/Owner Name Facility ID#(if applicable) FL ft - �41 t
104 Bayleaf Drive Raleigh, NC ft. tr. _a, ;311 `�- V. ,�
y�. ..pit ��p/`,1.�
Physical Address,City.and Zip ft. ft.
Wake ;:2LeREMARKS.
County Parcel Identification No.(PIN) "
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one hit/long is sufficient) 22.Certification:
35.91726 N -78.64486 W %ems
10/13/21
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contractor Date
Rv signing dus/orru, I herebv c'erh&that the uell(.$) was(,were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or JqNo woh ISA M AC 02C.0100 or I A NCAC 02C.0200 Well Comintcuon Standards and that a
IJ'this is a repair fill fill out known well construction information and explain the nature o f the copy 4/this record has been provided to the well ou tier.
repair under=2/remorks sec•Non or on the back of this Jitrnt.
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 site details or well
construction.only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:5 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
hor ntulople wells list all depths y different(example-3 6t.?00'and 20100') construction to the followine:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
{/water Ierel t.,above easnrg,ire " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1.5 (in.) 24b. For lniection Wells: In addition to sending the form to the address in 24a
Direct Push above,also submit one copy of this form within 30 days of completion of well
1 Well construction method: 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 SuvpIv& lniection Wells: In addition to sending the form to
the address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Qualiry-Division of Water Resources Revised 2.22-2016