GW1-2021-00047_Well Construction - GW1_20210401

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Construdon Electronic •
North Carolina Department of Environmental Quality
April 1,2021
Page 1
Submission ID#
GW 1-2021-00047
CONTACT INFORMATION
..................................................................................................................................... ......................................................................................................
Contact Name* Email Address*
TEST [e-mail]
Is this a revision to the form you have previously submitted?
f Yes r No
WELL CONSTRUCTION INFORMATION
.........................................................................................................................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Cert# Cert Level First Name Last Name Company Name
3,555 A WILLIAM ABERNATHY WILLIAM K ABERNATHY
2.Well Construction Permit#:
wg9999999
List all applicable well construction permits(i.e.fvbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3. Non-Water Supply Well* r Monitoring
r Recovery
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
4/1/2021 BR549 125
(gallons per minute)"

Page 2
5.Well Location
Facility/Owne r Name*
TEST Run Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Wake
Physical Address* Street Address
608 Garden Club Way
Address Line 2
City State/Province/Region
Wendell NC
Postal/ZZp Code Country
27591-5934 us
Latitude* 35.7918205000 Longitude*-78.3503449000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and a)plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
125 surface?
For multiple wells Iistall depths if different 10
(example-3 a200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
5 15
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other

Page 3
14.WATER BEARING/FRACTURE ZONES
From To Description
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
................................
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
*rJ 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 copy of this record has been provided to
the well owner.
23.Certification*
Signature of Certified Well Contractor
Submittal Date 4/1/2021