GW1-2021-02151_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Shawn Robert Davis . 14.WATER ZONES
We]I Contractor Name V�11 FROM ft TO ft DESCRIPTION
4246-A ��I� 9 2� 0.85 20.0 Groundwater
�pr Oes5ing e. ft.
NC Well Contractor Certification Number i 3� rrQI1 15.OUTf R CASING(for multi cased
iG�`� �t'N�¢'J FROM TO DIAMETERells ORT ICK\ESS a hLahle) AL
Froehling & Robertson, Ir1�. D
in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: N/A FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Pubhc 10.0 fL 20.0 ft' 2 Ot Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft, in.l
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Ill l ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. 5.0 ft Neat cement Tremie
x Monitoring ❑Recovery, 5.0 ft 8.0 ft Bentonite Gravity
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 8.0 It. 20.0 ft Well#2 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 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock rain size,etc
0.0 ft 2.0 ft- Asphalt over ABC Stone
4.Date Well(s)Completed: 6/14/2021 Well ID#WSE-MW-1 2.0 ft PO 0 fL Silty SAND
5a.Well Location: ft ft
City of Raleigh N/A ft. ft
Facility/Owner Name Facility ID#(if applicable) ft ft
S. West St., Raleigh, NC 27601 ft. ft
Pbysical Address,City,and Zip ft ft
Wake N/A 21 REMARKS,'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
35.776396973 N -78.646144479 W �•.�
6.Is(are)the well(s) Permanent 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 )No with 15A NCAC 02C.0100 or ISA 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 I 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 @ 20.0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
0.85'
10.Static water level below top of casing: (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. 8.25 (in.) 24b.For Iniection Wells: In 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&Iniection 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 ti the county health department of the county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016