GW1-2021-00665_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:
A4.WATER ZONES
Justin Radford FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3270 A ft. f,
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Wells)TO N=R Lif��TT&Z:
FROM TO DIAMETER
Geological Resources, Inc. ft. I ft. I in.
Company Name 16.-INNER CASING'ORTUBING(ge6thirmi7 closed-lootil A,
FROM TO DIAMETER TFUCKNESS MATERIAL.
2.Well Construction Permit 0 it. 10 fL 2 in. sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc) ft. ft. in.
3.Well Use(check well use): 47.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIUCKNESS MATERIAL
ElAgricultural OMunicipalftbfic 10 it- 25 it. 2 in. 0.010 sch 40 PVC
DGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
GROUT "t 7 -
1: , 77- 77
01ndustrial/Cornmercial DResidential Water Supply(shared) 18. 777
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rrigation 0 ft 6 fL grout : pour
Non-Water Supply Well: 6 it 8 it bentonite pour
@Monitoring DRecovery
Injection Well: ft. ft.
oAquifer Recharge OGroundwater Remediation 19.SAND/GRAVELTACK(if apOticible)
FROM TO -MATERIAL- EMPLACEMENT METHOD
OAquifer Storage and Recovery 0 Salinity Barrier 8 it 125 ft. Sand pour
0Aquifer Test DStormwater Drainage f, I ft.
OExperimental Technology OSubsidence Control 20.DRILLING LOG;attach addifloWE sheets ifnece I ssai-Y)
OGeothermal(Closed Loop) OTracer FROM _ TO DESCREMON(color,haWness,soilfrock type,grain size,etc.)
DGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft 0.50 fL Asphalt
10/28/2021 MW-1 0.5 ft 5 ft
Brown medium sand
4.Date Well(s)Completed: Well ID# 5 it. 15 it. fled/brown silt
5a.Well Location: 15 ft .20 ft. vdrw S-4-'k it
Poole Road Mart 00-0-0000005923 20 it. 25 it. Br
Facility/Owner Name Facility ID#(if applicable) ft. ft. fuzl
2121 Poole Road, Raleigh, NC 27610 ft. ft.
Physical Address,City,and Zip 21.REMARKS 9_0_4?
Wake 1713-67-1538
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lattlong is sufficient)
78.6085290 W r. I/z-, '_e]
35.7760540 N '�14DIZ zz
Signature ofCetifiedW'ell Contractor Date I
6.Is(are)the well(s): 2Permanent or OTemporary By signing this form,I hereby certify Ithate well(s)was(were)constructed in accordance
with IJA NCAC 02C.0100 or 15A NCAt 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or E]No copy ofthis 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:
1 You may use the back of this page ito provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLYwith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths i(different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: unknown -(ft.) Division of Water Reso i prees,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 Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 Ce6ter,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 helidth department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013