GW1-2023-00699_Well Construction - GW1_20230113

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 4475 ,. t�
ft. ft.
NC Well Contractor Certification Number (� 15.OUTER CASING-for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION JAN 1 20Z3 FROM TO DIAMETER THICKNESS MATERIAL
rt. ft. in.
Company Name -- ':+,•,'_ ,^.'^'=r-:� t ai,l
1fi•w+i "' ' 16.INNER CASING OR TUBING eother a[closed-loop)
rv -�i
2.Well Construction Permit#: ••'�--Tl-'I FROM TO DIAMETER THICKNESS MATERIAL
'
List all applicable well construction permits(i.e.UiC,County,State,lrarimtce,etc.) 0.0 ft. 25.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
I7.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 ft• 40.0 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- 21.0 ft. PORTLANDBENTONITE SLURRY
INMonitoring ❑Recovery ft. ft.
Injection Well:
ft. tr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a i licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 23.0 ft• 40.0 tt. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soilt rock e, nin size,etc.)
9Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 It. 1.0 It. CONCRETE
4.Date Well(s)Completed: 09/08/22 Well ID# MW-1 1.0 ft 10.0 rt• RED SILTY CLAY
Sa.Well Location: 10.0 ff 20.0 tf BROWN SILTY CLAY
COMMERCIAL PROPERTIES 20.0 ft• 40.0 ft. TAN SILTY SAND
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
313 WEST MARTIN STREET RALEIGH 27601 rt. ft.
Physical Address,City,and Zip
ft. ft.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-21.0-23.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 46' 37.22" 780 38' 39.59"
N w `'' � 09/21/22
6.Is(are)the well(s)• 291"ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this forin,I hereby certify that the irell(s)urns(here)consiructed in accordance will;
7.Is this a repair to an existing well: ❑Yes or MNo i5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cap)'
If this is a repair,fill out known well construction information and explain the nature of the oj'lhis recorcl iras been provided m the hell ou'rier.
repair under 421 remarks section or on the back oflhis•Jorin.
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 ofwells (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: 40.0 (ft.)
hlor multiple bells list all depths ifclyf&rent(example-3 n 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10. 25.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!fJ'irnier level is above coxing,use..+,•
$•0 24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to tlTe
(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 G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018