GW1-2022-10400_Well Construction - GW1_20221116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I J
Mike Radford 14.WATER ZONES
Well ContractorName FROM TO DESCRIPTION
4267-A f� &
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a Rcable
Bridger Drilling FROM I To DIAMETER TIDCKNFSS MATERIAL
ft. fL
Company Name
16.INNER CASING OR TUBING. eothermal closed-loon)
2.Well Constrtretion Permit#: FROM TO DIAMETER I TMCKNESS I MATFRML
List all applicable well construction permits(i.e.UIC,County,State,Variance etc.) ft. ft. in.
3.Well Use(checkwell use): % f, iEL
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TMCKNFSS MATERIAL
❑Agricultural ❑Municipal/Public 0 ft. 10 ft. 2 in. joint flush
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL 0 ft. in.
❑lndustrial/Commeroial ❑Residential Water Supply(shared) 18.GROUT
01rrigation ❑Wells>100,000 GPD FROM I To MATERIM. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 11 ft 14 ft. portland cement
MMonitoring ❑Recovery ft. fL
Injection Well:
fL ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK d applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I FAIPLACEMENTMETDOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control ft. f,
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if neces
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FRoM TO DESCRIPTION color,hardness,soorroex eta
0 & 10 fL orange silty clay
4.Date Well(s)Completed: ll/4/22 Well iD#MW1 10 fL 22 rL orange gray sandy clay
5a.Well Location: 22 ft. 25 ft• gray sandy clay
Ashton Woods ft. fL
Facility/Owner Name Facility ID#(ifapplicable) fL & �C U
:t,. tr
Hasentree Way and Sandytree Lane Wake Forrest,NC 27587 fL ft. l
Physical Address,City,and Zip
fL ft. 1
2022
Wake 21.REMARKS <: i_
.. ..:✓.Ya/Y�r� v i.i
County Parcel Identification No.(PIN) tl Jv:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36.00.15 N -78.35.51 W A 4-a'll 11/9/2022
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified well CbAfractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NC,1C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#21 remarks section or on the hack 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 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:25 (ft.)
For multiple wells list all depths if d fferenI(example-3@,2 0 0'and 2Q100 Submit this GW 1 within 30 days of well completion per the following:
21 24s. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft)
Ifwater level is above casing.use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
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 DWI?,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