GW1-2022-08805_Well Construction - GW1_20220909

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
John Eisenman 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4439 - A ft. ft.
ft. ft.
NC Well Contractor Certification Inc.umber 15.OUTER CASING for mulfi-cased wells OR LINER if a livable
SAEDACCO, n FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 rt. 85 rt. 6 i" Sch 40 PVC 16.INNER CASING OR TUBING(geothermal closed-loop)
N/A
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) 0 ft. 92 ft' 2 "' Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
C Agricultural DMunicipal/Public 92 ft. 97 ft' 2 in. 0.01 Sch 40 PVC
Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) ft. ft. in.
:]Industrial/Commercial []Residential Water Supply(shared) 18.GROUT
l Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 83 ft. Aqua Guard Tremmie
Monitoring []Recovery ft. ft.
Injection Well: tr. it.
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if appiivable
_ Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 89 ft- 97 ft. Sand#2 Pour
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soiltrock type,grain sin,etc.
0 ft. 70 ft. Brown'Silty fine sand and silt,mica,and relic rock structure
4.Date Well(s)Completed:07-28-2022 Well ID# MW 6CR 70 ft. 75 ft, PWR'-Brown sandy silt with relic rock structure
5a.Well Location: 75 ft. 97 ft. Bedrock
Corning Incorporated N/A ft. ft.Facility/Owner Name Facility ID#(if applicable) ft. ft. t U • '2022
3900 Electronics Drive, Raleigh, NC tr. tr.
ft.
Physical Address,City,and Zip ft.
Wake 17157891482 21.REMARKS
County Parcel Identification No.(PIN) Benton6te Sea' fFefn 83' te 89 .'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.832589 N -78.604500 W �� 09/01/2022
6.Is(are)the well(s)o Permanent or []Temporary tare of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or XDNO with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 411 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well t.depth below land surface: 97.0 f
P ( ) 24a. For All Wells: Submit this,foim within 30 days of completion of well
For multiple wells list all depths ifdiJferent(example-3@200'and 1@100') construction to the following:
10.Static water level below to of casing: Unknown ft.
P S: ( ) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 12 /6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
HSA/Air above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c. For Water Supply& Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to ithe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016