GW1-2023-02638_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Donald L. Wells 14.AVATER ZONES
41
1. FROM TO DESCRIPTION
Well Contractor Name 2023 25 ft 50+ ft surfacial aquifer
3583-A ft. ft.
NC Well Contractor Certification Number ...... 15.OUTER CASING for T!±Lcil''secl wells) livable
TER THICKNESS
N ATERIAL
FROM TO M
Soil & Environmental Consultants, PA 0 ft 30 12 1 sch 40 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. 17L in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
El Agricultural []Municipal/Public 30 50 IL 2 in. 0.010 sch 40 pvc
DGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) in.
DIndustrial/Commercial OResidential Water Supply(shared) .18.GROUT
FROM TO MATERIAL EMPLACEMENT'METHOD&AMOUNT
Ohrigation 0 ft. 4 ft. cement pour
Non-Water Supply Well:
10Monitoring ORecovery 4 rt. 29 fi- bentonite pour
Injection Well: ft ft.
OAquifbr Recharge 0 Groundwater Rernediation 19.SANDIGRAVEL PACK(ir applicable)
13 Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT I ENT METHOD
0 Aquifer Test 0 Stonnwater Drainage 29 ft- 50 ft. sand#2 pour
ft. ft.
DExperimental Technology D Subsidence Control
20.DRILLING LOG attach additional sheets if necessam)
DGeothernial(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,gnin size,etc.)
DGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 1 ' ft. 18 IL Sandy loam,reddish brown
4.Date*Vell(s)Completed: 3-14-23 Well IDN MW-3 18 ft- 45.5 1" Sandy.loam,tan to brown, some silty clay ler
45.5 't' 50 17L PWR,white quarts fragments,sand
5a.Well Location: ft. fL
Burlington Laboratory ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
NCSU, Dept.of Nuclear Engineering.Attn: Dr. Colby Fleming ft., ft.
Physical Address,City,and Zip 21.REMARKS
2500 Stinson Dr.,Rai.,NC 27695,Wake 0794507874 flush mount metal well cover,tagged&Locked by owner
County Parcel Identification No.SPIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
Grid Northing 741169.79 N Grid Easting 2098230.30W 4-3-23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to all existing well: DYes or El No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature ofthe
repair under 921 remarks section or on the back of this form. 23.Site diagratin or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (ft.) 24a. For All Wells: Submit this form vvithin 30 days of completion of well
For multiple wells list all depths itdifferent(example-3@200'and 2@ 100) construction to the following:
10.Static water level below top of casing: 39.92 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b. For Infection Wells ONLY: fit addition to sending the form to the address in
24a above. also submit a copy of this form within 30 days of completion of well
12.Well construction method: Hollow Stem Auger construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Proginna,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1 1
13a.Yield(gpm) Method oftest: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the count),where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013