GW1-2021-00663_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Sam Bowers FROM TO DESCRIPTION
Well Contractor Name ft ft.
3220-A ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER a licable
FROM TO DIAMETER THICKNESS MATERIAL.
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING 'eotherma]cldsed-loo`
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A 0 ft' 40 fl- 2 in. soh 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN is
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑MunicipaMblic 40 l" 45 ft. 2 1n. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fa fa in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 ft' 30 ft. grout pour
Non-Water Supply Well:
EMonitoring ❑Recovery 30 ft. 38 ft. bentoriite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
38 45 #2 sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets N necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock in sim etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 30 ft. 39 ft. Red clay/silt
4.Date Well(s)Completed: Well ID#
08/24/2021 TW-1 39 ft 45 ft' Sandy red clay/silt
ft. ft.
5a.Well Location: ft. ft.
Webb's Mini Mart 0-00024760 ft. ft. ly}
Facility/Owner Name Facility EW(if applicable) ft. ft. 'i
900 Poole Drive, Garner, NC ft. ft. DEC
Physical Address,City,and Zip 21.REMARKS:
Wake 1710-38-5288 DWR S 'T
County Parcel Identification No.(I'Do l' �11'+itr-S",s��y��r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.695698 N 78.616966 W 10/19/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo copy of this record has been provided to the well owner.
If this 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,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:45 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 11 .72 (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: 4.5 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Hollow stem/Mud rota 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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&Injection Wells:
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