GW1-2023-00701_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL _ _ - 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4459
J A y i 2OZ3 ft. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. in.
Company Name i' "
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit It: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) 0.0 ft, 5.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): fr. R. in.
Wafer Supply Well: 17.SCREENFROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft. 15.0 ft. 2.0 1 ' 1 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wel Is> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&ABIOUNT
Non-Water Supply Well: 0.0 ft' 3.0 ft' PORTLAND aENTONITE SLURRY
INMonitoring El Recovery fr. ft.
Injection Well: ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft. 15.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heat i ng/Cool ing Return) ❑Other(explain under 921 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft• 0.5 ft• CONCRETE
4.Date Well(s)Completed: 1 1/01/22 Well ID# MW-3 0.5 ft• 15.0 ff SILT
Sa.Well Location: ft. ft.
ZEBULON CLEANERS ft, ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
131 VANCE STREET ZEBULON 27597 ft. ft.
Physical Address,City,and Zip
ft. ft.
WAKE 2L REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL•••3.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
350 49' 19.77" N 780 18' 41.22" W
11/02/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing This forn,I hereby certify that the wells)mac(were)constructed in accordance iridt
7.Is this a repair to an existing Well: ❑Yes Or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
flhis is a repair,fill out known well construction information out explain the nature ofthe aflhis record has been provided to the well owner.
repair under a2l rennarks section or on the back ofthis•form.
23.Site diagram or additional well details:
S.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-I 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: 15.0 (ft.)
For nnti/liple wells list all depths'ifdiJJereni(example-3@200'and 2@100')10. Submit this GW-1 Within 30 days of Well completion per the following:
8.0 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
Iflrater lovel is above casing,use"+"
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
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 DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-I North Carolina Department offinvironniental Quality-Division of Water Resources Revised 6-6-2018