GW1-2022-09900_Well Construction - GW1_20221028

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WELL ONSTR TION RECORD(GA-1) For Internal Use Only:
1.Well Contractor Information:
Daniel -On'66rs 14:NVATER:ZONES
Well Contractor Name FROM TO DESCRIPTION
10 ft. 20 ft.
2579-A ft ft
NC Well Contractor Certification Number IS.OUTER CASING focmhlli cased`we71s ORGINER ita`livable
Carolina Soil Investigations, LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 1 10 f' 2 m I Sch 40 PVC
16.INNER CASING OR'TUBIN0 eoihermal closed-loo
2.Well Construction Permit#: Meek SIP#70002885 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. to
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 10 ft. 20 ft. 2 i" 010 Sch 40 pvc
Geothermal(Heating/Cooling Supply) I71 Residential Water Supply(single) fL ft. in
Q Industrial/Commercial 171 Residential Water Supply(shared)
'18.GROUT
Irrigation ;
Il Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rL 5 ft• portland mix&Pour
©X Monitoring 1771 Recovery 5 ft. 8 ft bentonite tremie
Injection Well: ft. ft.
Aquifer Recharge FI GroundwaterRemediation
+19rSAND/GRAVEL'PACKifa IicaGle =
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage 8 ft 20 ft 10/30 silica sand tremie
Experimental Technology 1771 Subsidence Control ft. ft.
Geothermal(Closed Loop) 171 Tracer .20'DRILLINGLOG attachadditional'sheets ifnecessajry)''
Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness sofl/mck rain size,' etc.
0 ft 20 fL brown silt loam/brown sil ' • 4_ "gip e;
4.Date Well(s)Completed:08-23-22 Well ID# B-4 ft. ft
r
5a.Well Location: ft. ft. 2 i9 22
Duke Substation ft. ft:
ITIr^-M�
Facility/Owner Name Facility ID#(ifapplicable) ft ft r"a� ti,au 11 tlfiit
West Jones and North West St Raleigh, NC ft ft v `fit
Physical Address,City,and Zip
ft ft
Wake
21irREMARKS.•"<' _ -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certt a ion:
35.78267 N -78.64650
08-23-2022
6.Is(are)the well(s):X®Permanent or rl Temporary Signature of ertified Well Wwrmctor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or Q No 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#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 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: 'I
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20 (ft.)
For multiple wells list all depths if different(alrample-3 rr 00'and 2@100') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: (ft.)If water level is above casing,use"+" Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 101,
(in.)
24b. For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: auger above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) Construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SunDly& Iniection 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!the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018