GW1-2021-02194_Well Construction - GW1_20210721

1
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford 04...WATEWZONES° F ,x <... ..� R
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3270 A nC ft. ft.
NC Well Contractor Certification Number ���� S.:OUTER4GtTOtNG for,.mul DIAMETER
il�iells AR';LINERa if a licatile
FROM TO DITAMETER THICKNESS MATERIAL
Geological Resources, Inc. " ft, ft.
Company Name f
c[r;,atrosl
',�[CCe 4.1klit
.,INNER;CAS NG{ORSTUBINGi eothernallclosed:too'
tilt p1,pJ is Sscron FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 3 ft. 2" in. SCh 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
tt. tt. in.
3.Well Use(check well use): 1715GREEN
Water Supply Well: FROM TO DIAMETER'i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 tt. 13 ft• 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 cement pour
Non-Water Supply Well:
OMonitoring ❑Recovery 1 tt. 2 tt. bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ,:19a'SAND/Git8,VELI�Y GKI(if.iAp—Olieable'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 ft. 13 ff 'Sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control0`DRtI LiNGsLOGs a`acli,additionals'tieetslif.neces"s`a."` . F ,'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soittrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 2 Red clay
06/14/2021 MW-11 2 ft- 7 ft. Gray clay
4.Date Well(s)Completed: Well ID# 7 ft, 9 ft. Watery gray clay
5a.Well Location:
9 ft• 13 ft• Brown/gray clay
600 Glendon Way Property n/a
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
600 Glendon Way, Cary, NC
Physical Address,City,and Zip �21.REN1ARKS ` ." & �M Mw
Wake 0734-75-7973 :g�� .-
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one laOong is sufficient)
35.799268 N 78.871794 W 06/18/2021
Signature of Certified Well Contractor, Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the well(,)was(were)constructed in accordance
with I5A 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 FIND 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 ofthi.s 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 13 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d fferent(example-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: n/a (fL) Division of Water Resources,` reformation Processing Unit,
Ifwaler level is above casing,use"+" 1617 Mail Serviee�Center,Raleigh,NC 27699-1617
n
11.Borehole diameter: 3.5 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Hand au er 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g 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