GW1-2021-00666_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 4
3270 A ft. % i
NC Well Contractor Certification Number 15.OUTER CASING"for mulii-eaeed;wells`ORLINER ,i.Hcable .
FROM TO DIAMETER I THICKNESS I MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASING ORTUBING`eoihermahcldiid-loo' <
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in
0 9 2 sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft ft.
3.Well Use(check well use): 17JSCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 9 ft. 29 ft. 2 is 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) iS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 5 ft rout
Non-Water Supply Well: 9 pour
OMonitoring ❑Recovery 5 fL 7 ft- bent6nite pour
Injection Well: % fL
❑Aquifer Recharge ❑Groundwater Remediation .`19.SAND/GRAVEL'PACK if a `licable
MATE
❑Aquifer Storage and Recovery ❑Salinity Barrier 7 ft. 29 FROM TO ft. I RIAL EMPLACEMENT METHOD
Sand pour
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control 20.`DRILL
INGLOG attach aitditional"sheets f neeessa"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUrack type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 0.25 ft. Asphalt
4.Date Well(s)Completed: Well ID#
11/10/2021 MW-1 0.25 ft- 1 ft. Gravel
1 fA 8 ft. Orange clay
5a.Well Location: 8 ft 11 ft. Red-tJ"Wa
A & K Food Mart 00-0-0000005385 11 ft 20 & Brown clay with n edium sand
Facility/Owner Name Facility ID#(if applicable) 20 ft. 29 ft. Brown me ku
1307 E Williams Street, Apex, NC 27502-0220 ft.
Physical Address,City,and Zip
31.REMARKS' MADU m
Wake 0741-75-2593 oto
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.7157830 N 78.8409550 W 12/07/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA 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
S.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: 29 (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: 15.90 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Servime 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
SOlIdi tit 24aabove, also submit a copy of this form within 30 days of completion of well
au er
12.Well construction method: 9 9 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
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24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Watei Resources Revised August 2013