GW1-2021-06185_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Todd Muench 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3371
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for.multi-cased'wells OR LINER if a lHE2ble
Parratt-Wolff, Inc.I FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
WI0501084 16.INNER CASING'OR TUBING eotherinatclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft in.
3.Well Use(check well use): ft. rt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER ! SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 0 {t. ft. in.:
il Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) ft. ft. to
J Industrial/Commercial Residential Water Supply(shared) 18.GROUT
J 17r1 atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
J Monitoring ®Recovery {t ft.
Injection Well: ft ft.
Aquifer Recharge J Groundwater Remediation '
19.SAND/GRAVEL-:PACK(if a 'liable
J Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [ Stormwater Drainage
Experimental Technology I[�J Subsidence Control
J Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
J Geothermal(Heating/Cooling Return) Ell Other(explain under#21 Remarks) FROM ft ft.TO DESCRIPTION color,hardness,soittrock type,grain size,etc.
4.Date Well(s)Completed: 10/11/21 Well ID#I P-29 - I P-32 ft. ft.
5a.Well Location: ft. ft
William Newton ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft OCT 2 5 20
104 Bayleaf Drive Raleigh, NC ft. ft. n
Physical Address,City,and Zip ft. ft. iniorrnaliull
DAIR ciIOP
Wake 21.REMARKS
County Parcel Identification No.(PIN) "
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certification:
35.91726 N -78.64486 W -;�w �y��
10/13/21
6.Is(are)the well(s)�IJ Permanent or J Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or J No with 15A NCAC 02C.0100 or 15A NCAC'02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 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 ito provide additional well site details or well
construction,only 1 GW-1 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
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1.5 (in.) 24b.For Infection 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
12.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 Supply&Iniecti n 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 t d the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20I6