GW1-2022-07948_Well Construction - GW1_20220823

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: j
CARL CARPENTER 14.WATER ZONES 1 'i
FROM TO DESCRIPTION
Well Contractor Name p
ft. ft.
A - 4475
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased;wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO In
! THICKNESS MATERIAL
a. tr. � in.
Company Name 16.INNER CASING OR TUBING eother at closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc) 0.0 ft- 33.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. tr. in.
17.SC
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 33.0 ft' 43.0 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
❑irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 28.0 ft• PORTLANDBENTONITE SLURRY
MMonitoring ❑Recovery R, ft.
Injection Well:
tr. 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 31.0 ft• 43.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control R, 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,soill rock type,grain size,etc.
0.0 ft. 1.0 ft. ASPHALT/CONCRETE
4.Date Well(s)Completed: 08/04/22 Well ID# MW-6 1.0 ft. 20.0 ft. BROWN SILTY SAND
5a.Well Location: 20.0 e' 30.0 ft- BROWN SILTY CLAY
POPES DRY CLEANER 30.0 ft• 43.0 ft' TAN SILTY SAND
Facility/Owner Name Facility ID#(ifspplicable) ft. ft. -
1408 CORPORATION PARKWAY RALEIGH 27604
Physical Address,City,and Zip ft. ft. A.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONrfE SEAL-28WP39t.0' }'.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/iong is sufficient) 22.Certification:
350 48' 00.43" N 780 34' 03.49" N ;j' 08/16/22
6.Is(are)the well(s): 09Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,/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.0100 or MA NCAC 02C.0200 Well Construction Standards and that a copy
Jfthis is a repair,fill out known well construction information and explain the nature ofthe olthis record has been provided to the well owner.
repair under_21 remarks section or on the back gJ7hislorm.
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-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: 43.0 (ft•) Submit this GW-1 within 30 days of well completion per the following:
lvhr multiple wells list all depths ifdiJJercnt(example-3 n 200'and 2 t@100')
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20.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1/lwater 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 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources) Revised 6-6-2018