GW1--07752_Well Construction - GW1_20231201

1
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Donald L. Wells IWAT.ER`ZONEs ::;,a -;
FROM TO DESCRIPTION
Well Contractor Name 40 ft 50+ It I ; surfacial aquifer
3583-A ft. ft. I I
NC Well Contractor Certification Number .15.OUTER CASING'(for multi,cased:wells)OR LINER(if ap'licable) - -
FROM TO - DIAMETER THICKNESS MATERIAL
Soil & Environmental Consultants, PA o it• 30 ft 2 in. sch 40 pvc
16.INNER'CASING OR'TUBING eothermal.closed`--too
Company Name (R p)'`' `•'
FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft in.
List all applicable well permits(i.e.Counry,State,Variance,Injection,etc.) - - -
ft. ft hi.
3.Well Use(check well use): - :,
�17sSCREEN.: � ..- -. -
Water Supply Well: FROM , TO , DIAMETER SLOT SIZE THICKNESS MATERIAL '
❑Agricultural ❑Munieipal/Public 30 ft 50 ft 2 in' ! 0.010 sch 40 pvc
I
❑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
❑Irrigation 0 ft. ft j
Non-Water Supply Well: •5.8 cement _ pour
OMonitoring ❑Recovery 5.8 ft 29 ft bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation ':19.SAND/GRAVEL PACK(if applicable) . ..
FROM ' TO MATERIAL: EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 29 rt. 50 ft sand'#2 pour
ft. It.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) -
❑Geothermal(Closed Loop) 0 Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 4 ft fill Sandy Clay loam,reddish brown
10-11-23 MW-4 4 ft. 9 ft Sandy loam,tan to brown,some silty clay ler
4.Date Well(s)Completed: Well ID#
9 ft 50 ft Silt,Sandy loam,few clay lenses,light gray,1
5a.Well Location: ft ft r'^
Burlington Laboratory ft ' ft ' I • `' .,..f,� 1 fr -k/
Facility/Owner Name Facility ID#(if applicable) ,�J='
ft ft ! C J 1 2023
NCSU, Dept. of Nuclear Engineering. ft ' ft i
Physical Address,City,and Zip ,r , ._ -' I y':
21.REMARKS . _ -
2500 Stinson Dr.,Rai.,NC 27695,Wake 0794507874 ;.:,..,-,.-,.,,-;.0;-:,
flush mount metal well cover,tagged&Locke -owner
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: I
22.Certification:
(if well field,one latilong-is sufficient)
741025.31 N 2098188.77 Grid Easting w ���, ( I(,�,�,G 10-30-23
Signature o Certified Well Contractor , Date
6.Is(are)the well(s): ©Permanent or ❑Ternpor•ary By signing this form,I hereby certin,that the well(s)was(were)constructed in accordance
with.I5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E 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 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: 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 I
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (ft.) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 42.5 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: Iniaddition to sending the form to the address in
Auger 24a 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 Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ceder;Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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 county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013