GW1--00507_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORD 'For Internal Use ONLY: '
This form can be used for single or multiple wells
I
1.Well Contractor Information:
14.WATER ZONES
Matt Steele FROM TO DESCRIPTION
Well Contractor Name ft. ft. I'
4548-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. I 'I in._
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WM0501591 FROM TO DIAMETER THICKNESS- MATERIAL
2.Well Construction Permit#: 0 ft• 5 ft• 2 i In. Sch 40 PVC
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
DAgricultural ❑Municipal/Public 5 ft. 20 it. 2 in. 0.010 SCh 40 PVC
❑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. 1 ft• grout; pour
Non-Water Supply Well:
Monitoring ❑Recovery 1 ft. 3 ft• bentonite pour
Injection Well: ft. ft.
-
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier S ft. 20 ft• #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)'.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.6 ft• I Concrete
11/14/23 MW-13 0.6 a• 11 ft. Silty clay
4.Date Well(s)Completed: Well ID#
11 ft. 15 ft. Clay
5a.Well Location: 15 ft• 20 ft. Clay
Apex Food Mart 0-00-0000006819 - ft. ft
Facility/Owner Name Facility ID#(if applicable) "�"' -'' a � ^�-
321 South Salem Street, Apex, 27502 ft• f• JAN 1 S 2024
Physical Address,City,and Zip 21:REMARKS„ °. - I.-.4%'
Wake 0741394692 CY C:'30G
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.727427 N 78.853966 W ' ; 11/14/23
Signature of Certified Well Contractor,, Date
1
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I hereby certify that the xell(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 an existing well: ❑Yes or ENo 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 3
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this,form 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: 1
10.Static water level below top of casing: 11 .28 (ft.) Division of Water R e sources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Servic i Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Injection Wells ONLY:.In 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
Solid Stem Auger
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 Center,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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013