GW1-2022-05175_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.NVATER ZONES
Well Contractor Name FROM ft. TO DESCRIPTIONft.
A - 4475 _ ft. fr.
NC Well Contractor Certification Number 7 P t
6 2 ;% a_ _J 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION � '"R"`Y FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name MAY 3
16.INNER CASING OR TUBING eother al closed-too
2.Well Construction Permit#: IWO FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits#.e.UIG CfNT ''S �e':�'aFi h 0.0 ft. 15.0 ft. 2.0 '"' SCH 40 PVC 3.Well Use(check well use): ft. fr. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15.0 ft' 30.0 ft. 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single)) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 11.0 ft' PORTLANDBENTONITE SLURRY
I!flMonitoring ❑Recovery ft. fr.
Injection Well:
rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 13.0 ft• 30.0 ft' 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 421 Remarks) FROM TO DESCRIPTION color,hardness,soil(mck type,ginin size,etc.
0.0 ft. 1.0 ft. ASPHALT
4.Date Well(s)Completed: 03/29/22 Well ID# MW-4 1.0 ft. 10.0 ft. RED CLAY
5a.Well Location: 10.0 ft. 20.0 ft' BROWN SILTY SAND
POPES DRY CLEANERS 20.0 ft• 30.0 1" TAN SILTY SAND
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1408 CORPORATION PARKWAY RALEIGH 27604 fr. ft.
Physical Address,City,and Zip ft. ft.
WAKE 21.REMARKS, I
County Parcel Identification No.(PIN) BENTONITE SEAL- 11.0-13.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
350 48' 02.13" N 780 34' 04.57" WC- 04/04/22
6.Is(are)the well(s)• Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the we/l(s)eras(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I1flNo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section or on the back oJ'ihis Jornu.
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 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30.0 (ft.)
Fornnthiple wells list all depths ifdl/Jereni(example-3 a200'and 2a 100') Submit this GW-1 within 30 days of well completion per the following:
16.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f water level is nbore casing,use"+"
11.Borehole diameter: 8.0 (in,) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018