GW1-2022-03343_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: C
CARL CARPENTER 14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4475
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name
16.INNER CASING OR TUBING eothermal closed-loop
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 5.0 ft. 2.0 '"' ScH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 r" 15.0 ft' 2.0 "' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 00 ft. 10 ft. PORTIANDBENTONITE SLURRY
OMonitoring ❑Recovery
Injection Well:
ft. ft.
❑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 3.0 rt 15.0 rt' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑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,soil/rock type,train size,etc.
0.0 rL 15.0 rr• SANDY RED GRAVEL
4.Date Well(s)Completed: 02/09/22 Well ID# MW-3 ft. a.
Sa.Well Location: ft. ft.
CIRCLE K - 2723479 ft. ft.
AR 14
Facility/Owner Name Facility]Did(ifapplicable) ft. ft. H.
1900 HIGHWAY 70 EAST GARNER 27529
Physical Address,City,and Zip
ft. ft.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 1.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 04' 09.98" 770 01' 27.84"
N wl =` 02/18/22
6.Blare)the well(s): TPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [5No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a caw
l/'dNs is a repair,Jill out known well construction information and explain the nature o/7he ofthis record has been provided to the well owner.
repair under 021 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 construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
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drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15.0 (ft.)
Vor nmhiple wells list all depths ifdifjerent(example-3 cGd200'and 2 n 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 10.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Iflvater level is above casing,use"4" i
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy toIDWR,Underground Iniection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER I `
24c.For Water Supply and Open-Loon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh',NC 27699-161 1
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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