GW1-2022-07946_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I.
DAVID HALL 14.WATER ZONES�
Well Contractor Name FROM TO DESCRIPTION
A - 4459
ft. ft. �!
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased?•welts OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICIflVESS MATERIAL
ft. ft. i in.
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 in. $CH 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 "' 15.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri at10n ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 ft' PORTLANDBENTONUE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well: 19.SAND/GRAVEL PACK if a lice
ft. ft.
❑Aquifer Recharge El Groundwater Remediation
file
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft- 15.0 r" 20-40 FINE SILICA SAND
❑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,soiVrock e, rain sim,etc.
0.0 ft- 1.0 ft- ASPHALT/GRAVEL
4.Date Well(s)Completed: 06/1 6/22 Well ID# MW-1 1.0 ft• 15.0 ft' CLAYEY SILTY SAND
ft. ft.
5a.Well Location:
AMERIKING FOOD MART ft. ft. "'; " "
Facility/Owner Name Facility ID#(if applicable) - ft. ft. i Ali r J -j
1709 LAKE WHEELER ROAD RALEIGH 27603 ft. ft. I Ung
ft. ft.
Physical Address,City,and Zip
WAKE 21.REMARKS,
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 45' 36.66" N 780 39' 39.56" W
06/22/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0l00 or 15A 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#21 remarks section or on the back ofthis form. i
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-1 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: 15.0 (ft.)
For multiple wells list all depths ifdii ereni(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
i
9•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 above 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
Permit Program,1611 MSC,Raleigh,!NC 27699-1611
13a.Yield(gpm) Method of test:
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13b.Disinfection type: Amount: f
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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