GW1-2022-07949_Well Construction - GW1_20220823

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14 WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 4459 e. iL 1
ft. ft. ! �
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedwells OR LINER"if a licable '
GEOLOGIC EXPLORATION FROM TO DIAMETER: THICIavESS MATERIAL
ft. I ft. I 1 in.
Company Name
INNER CASING OR TUBING(Fe othermalclosed-loo
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft, 15.0 ft. 2.0 rn' SCH 40 PVC
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN'.
FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 15.0 rt 25.0 rt• 2.0 in. 010 SCH40' PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) i, ft in.
❑IndustriaVCommercial ❑Residential Water Supply(shared) I&GROUT71,
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 10.0 rt• PORTLANDB'NTONITE SLURRY
(Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a' lica ble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT ME TIOD
❑Aquifer Test ❑Stormwater Drainage 13.0 ft. 25.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. fL
❑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,grain size,etc
0.0 ft- 25.0 It- SILTY CLAY
4.Date Well(s)Completed: 07/05/22 well ID# MW-5 ft. ft.
Sa.Well Location: ft. ft. ::Y C-0
LAKE BOONE CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ! 1 I
2508 WYCLIFF ROAD RALEIGH 27607 ft. ft < t i'r,^c • n3 Ur 4
Physical Address,City,and Zip ft. ft. v4r'J,lti
WAKE 21�REMARKS'-'
County Parcel Identification No.(PIN) BENTONITE SEAL- 10.0-13.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 49' 03.57" N 780 41' 33.78" W
a`"Z' I-ClIm-1 07/18/22
6.Is(are)the well(s): (EPermanent or ❑Temporary Signature of Certified 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.0100 or 15A NCAC 02C!0100 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 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-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: 25.0 (ft.
For multiple wells list all depths ifdifferent(example-3(200'and 2@100) ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20.0 (ft) 24a. For All Wells: Original fonni to Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injecti6n Control(WC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Opeu-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