GW1-2021-03542_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
of 14.I WATER ZONES
Lawrence D. O
PP FROM TO DESCRIPTION:
Well Contractor Name
i
NC 3322-A
NC Well Contractor Certification Number dS:OUTER CASING(for multi-cased wells)OR LINER if a"licable FROM TO DIAMETER THICKNESS MATERL4L
Regional Probing Services ft. fr. In.
Company Name 16.INNER CASING OR Tt18LNG eottermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft. 1 iln• Soh 40 PVC
List all applicable imll construction permits(i.e.C'oumy.Stale,Variance,etc.)
ft. ft. 'in.
3.Well Use(check well use): 17.SCREEN .._,
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft' 20 rt• 1 1°' 010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT,
FROM TO MATERIAL EMPLACEMENT METHOD&A-MOUNT
❑Irrigation 0 ft. 3 ft• cement grout pour
Non-Water Supply Well:
3 rt. g ft- bentonite pour
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL TACK if anwhicalil .
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. fr.
❑Aquifer Test ❑Stormwater Drainage 9 20 #2 sand pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addttional4stieets ifni:cessary .
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardness,soillrock is e,stmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 f` 16 rt• Silty/Clayey Sand
4.Date Well(S)Completed: 5/21/2021 MW-2 16 f`' 20 f`' weathered rock/Saphrolite
rt. rt.
5.Well Location:
Minnie L. Moore Property ft. ft. ,m,0%J § v
Facility/Owner Name Facility IDS(if applicable) ft. ft.
703 Rock Quarry Road, Raleigh
Physical Address,City,and Zip 1
21aiE1V1ARKS
Wake 'dR SscYion
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification °b'°1y g ed� ROOPe
(if well field,one lat/long is sufficient) awre
�.e°u°vsMa�n ou
35.770911 N 78.620102 W Opper " 5/26/2021
Signature of Certified Well Contractor i Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)teas(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 ElNo copy ofthis record has been provided to the well owner.
Iflhis is a repair,fill as known well construction information and explain the nature ofthe
repair under 1121 remarks section or on the back q/this fitrm. 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 ifnecessary.
For multiple injeciion or non-water supply wells ONLY with the same construction,you can
submit one.jornh. 24.Submittal Instructions:
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 ifderent(e>onrp/e-3C200'and 2@I00� construction to the following:
10.Static water level below top of casing:
approx 15 (ft.) Division of Water Quality,Information Processing Unit,
lfwater Icivl is above casing.use"i" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter. 2.5 (in.) 24b.For Infection Wells: In addition to sending the fonn to the address in 24a
Geobe-DP above, also submit a copy of this!form within 30 days of completion of well
ro
12.Well construction method: P construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.) I
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 Sunoly&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. j
Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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