GW1-2021-05286_Well Construction - GW1_20210601

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells i
L Well Contractor Information: q�� �
Justin Radford ��� 4•1�vATERZONES�*' fir.
FROM TO DESCRIPTION
Well Contractor Name 10 ff 20 Gray sandy clay
3270 AIN .X 1 ZO2� ft. ft•ft.
Unit
NC Well Contractor Certification Number proeeSSln9 JS.:OUTER'GASInG'fo[multrcliseil 119 ORlINER if a licatile
Informr31iol FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. D%NR Se° 0111
Company Name T&DINNER CASING OR.TUBING j6d1herinaFdose-sliio
FROM TO DIAMETER i"' THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft. 10 tt. sch 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) 0 2
ft. ft. in.
3.Well Use(check well use): WMISGREEN �,.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft. 20 ft• 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply �I8•GROUI v '_ � �
pp y(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT s
❑Irri ation 0 it. 6 rt. grout pour
Non-Water Supply Well:
OMonitoring ❑Recovery 6 it. g it• bentonite pour
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ?;19:SAND/GRAVE> PACK if,1 "licable x '
FROM TO MATERIAL EMPLACEMENT METHOD-
❑Aquifer Storage and Recovery ❑Salinity Barrier g ff 20 ff #2 Sand pouf
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20r=DTtII;L;TNG=IOG"<atta'cti additional..sheets�if necessa'�°� "�).
❑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• 0.50 fL Concrete
4.Date Well(s)Completed: Well ID#
04/12/21 MW-7 0.50 rt• 3 ft. Brown clay with medium sand
3 ft. 8 ft. Orange brown clay with medium sand
5a.Well Location: 8 fr. 16 rt. Gray with red clay
Speedway#8291 0-00-0000035938 16 ft• 20 ft• Brown sandy clay
Facility/Owner Name Facility ID#(if applicable) ft. ft.
100 Broad Street, Fuquay-Varina, NC
Physical Address,City,and Zip
Wake 0657923751
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one latAong is sufficient)
35.598280 N 78.800012 W 04/23/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): I7Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 1 JA NCAC 02C.0100 or i5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo copy ofthis 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 921 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths ifdii ferent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 10.28 (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: 6 (in.) 24b. For Infection Wells ONLY: in addition to sending the form to the address in
It 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 6 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 m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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