GW1-2021-02078_Well Construction - GW1_20210702

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Shawn Robert Davis 14.WATER ZONES ,.
Well Contractor Name N, I tu FROM TO DESCRIPTION
4246-A R ✓ 01 20.40 ft' 45.0 ft' Ground water
NC Well Contractor Certification Number O 2021 15.OUTER CASING for multi-cased wells OR LINER if a licable
Froehling & Robertson, Inc. ,16;1 FROM TO DIAMETER THICKNESS MATERIAL
V ft. fL in.
Company Name o` `,3t� R S�CIiOn 16.INNER CASING OR TU13ING jeothermat closed-loop)
2.Well Construction Permit#: 0 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN ;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 fL 45.0 ft. 2 1n' .01 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 15.0 ft. Neat cement Tremie
X)'Monitoring ❑Recovery 15.0 ft- 18.0 fL aentonite Gravity
Injection Well:
ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 18.0 ft. 45.0 ft. Well 42 Gravity
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soillrock type,grain size,etc.
0.0 ft. 5.5 ft. Clayey Silt
4.Date Well(s)Completed: 6/1/2021 Well ID#WSE-MW-2 5.5 R- 6.5 ft. Coal
5a.Well Location: e.5 fa 10.5 IL Silty Clay
Raleigh Union Station/City Of Raleigh N/A 10.5 ft 39.0 ft, Silty Sand
Facility/Owner Name Facility ID#(ifapplicable) 39.0 I'L 45.0 ft. Weathered Rock
510 W. Martin St., Raleigh, NC 27601 ft. ft.
Physical Address,City,and Zip ft. ft.
Wake 1703476921 21.REMARKs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.77605399 N -78.64631151 W
��� D":-o W? Zo 2
6.Is(are)the well(s)oPermanent or ❑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: ❑Yes or nNo with 15A NCAC 01C.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 to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 t'C7)45.0- (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 to of casing: 20.40 (ft.
P g� ) 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: 8.25 m. k
( ) 24b.For Infection Wells: hi addition to sending the form to the address in 24a
Auger 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&Infection 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 to 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 2-22-2016
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