GW1--03422_Well Construction - GW1_20230518

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. upper 14.,WATERZONE5
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING.for multi-cased wells OR LINER if a 'licable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft.
in.
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 32 ft. 1.25 '"' SCh 80 Steel
List all applicable well construction permits(i.e.County,Stale,Variance,etc)
ft. ft. in.
3.Well Use(check well use): 17.:SCREEN .
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
[]Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 7 fL gentonite pour
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
El Aquifer Recharge ©Groundwater Remediation 19:SAND/GRAVELPACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
7 rt. 35 ft- Natural Formation
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 DRILLING LOG attach.additional"sheetsifneceas
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 0.5 & Asphalt over crushed stone
4.Date Well(s)Completed:
4/11/2023-4/12/2023 0.5 ft- 35 ft. tan-brn sandy Silt
ft. ft.
5.Well Location:
ft. ft.
Former Piedmont Air Conditioning ft. ft. j L^
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1310 Nowell Road Raleigh
Physical Address,City,and Zip
21 REMARKS
Wake Temporary Geoprobe Injection Points(IP-'1, IP-2, IP-3)
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) Dlyttallymgnedty awe ceopper
Drc cn=lawrence Opper,o=Peglonal
35.798137 N 78.73307 W Lawrence Opper'emalk�sry@Mgioonalpmbing. m.c-OS 4/24/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 'ONo 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 of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 3 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 one form. 24.Submittal Instructions:
9.Total well depth below land surface: 35 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@I00') construction to the following:
10.Static water level below top of casing: approX 30 (ft) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 11617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1.25 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Geoprobe Direct-Push above, also submit a copy of this,form within 30 days of completion.of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Sui mlv&Geothermal 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 Environment and Natural Resources-Division of Water Quality Revised Ian.2013