GW1-2021-06924_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I
�o �jp 14.WATER ZONES
JACOB MESSICK
-s' '� y� ► FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A -4252 Pei�Y X 2021 ft. tt.
NC Well Contractor Certification Number l)i� 15.OUTER CASING for multi rased wells OR LINER-if a lieable -
GEOLOGIC EXPLORATION, INr+y�' ita c f�p� oM ft To ft DIAMETERin TmclavEss MATERIAL
Company Name 16.INNER CASING OR Tl)BING iothermaliclosed-loop).
FROM I TO DIAMETER THICKNESS MATERIAL,
2.Well Construction Permit#: 0.0 ft 35.0 ft- 2.0 in' SCH 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc)
ft. ft. in.
3.Well Use(check well use): 1Z SCREEN
Water Supply Well: FROM TO - DIAMETEW .SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35.0 ft- 45.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT;
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrl ation 00 ft. 280 It. PORTLAND6ENTONITE SLURRY
Non-Water Supply Well:
ft. ft.
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
31.0 f° 45.0 ft• 20-40 FINE SILICA SAND
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑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) 0.0 ft• 3.0 tt FILL
4.Date Well(s)Completed: Well ID#
09/02/20 MW-17D 3.0 ft- 15.0 ft- RED/BROWN SILTY SAND
15.0 ft• 45.0 ft• TAN/BROWN SILTY SAND
5a.Well Location:
SPEEDWAY - 6959
fr. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2808 US HIGHWAY 70 EAST CLAYTON 27520
ft. ft.
Physical Address,City,and Zip
21:REMARKS
JOHNSTON BENTONITE SEAL FROM 28.0 TO 31.6 FEET
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certificafion-
(if well field,one lat/long is sufficient)
350 40' 30.64" N 780 31' 12.84" W 09/21/20
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 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No cop),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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 45'0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 15.0 (ft) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
AUGER 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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submiti 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.
i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

c s
409 Rogers View Court
Raleigh,NC 27610
Mid Atlantic office919.250.9918
Engineering&-Environmental Solutions facsimile 919.250.9950
MAAONLINE.COM
April 26, 2021
Division of Water Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: WELL CONSTRUCTION RECORDS
SPEEDWAY 6959 - NCDOT RIGHT OF WAY
HIGHWAY 70 BUSINESS & GUY ROAD INTERSECTION'
CLAYTON,NC
MID-ATLANTIC JOB NO. R2728.09
To Whom It May Concern:
On behalf of Speedway LLC, please find the enclosed GW-1 forms for two monitoring
wells constructed at this site on August 31 and September 2, 2020. This work was
conducted under NCDEQ Permit WM0501401, issued on July 28, 2020.
Thank you.
Sincerely,
MID-ATLANTIC ASSOCIATES, INC.
Raymond S. Marchant, III, PG
Principal Geologist
Enclosures: GW-1 forms, MW-16D and MW-17D
EXPERIENCED CUSTOMER FOCUSED INNOVATIVE
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