GW1-2021-05781_Well Construction - GW1_20211015

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Sam Bowers WATER zoNEs DESCRIPTION
Well Contractor Name �^"�'a =s ft. ft
3220 A r O, ft. ft. i
~ ;11'S.OUTER CASING for multi-cased wells OR LINER'if applicable)
NC Well Contractor Certification Number r� 1 '� - . FROM TO DIAMETER TH[CIINESS MATERIAL
Geological Resources Inc. �C. it. ft. in.
�;;�
Company Name ,; n
r 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +;+' 0 fG 15 ft- 2 in. soh 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc) ft. ft. in
3.Well Use(check well use): 1`7.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft. 35 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
❑Irri ation 0 ft. 11 ft. Grout Pour
Non-Water Supply Well:
EMonitoring ❑Recovery 11 It• 13 ft• Bentoriite Pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 13 ft• 35 It' Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets it necessary) '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soWrock type,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.50 ft. Asphalt
4.Date Well(s)Completed: 07/13/21 Well ID#MW-1 0.50 IL 3 ft. Rock and brown backfill
3 ft. 6 ft. Gray silty sand
5a.Well Location: 6 ft. 7 ft Wethered rock granite
Phillip Food Mart 00-0-0000035416 7 ft. 13 It• Light brown medium sand
Facility/Owner Name Facility ID#(if applicable)
3616 Poole Road, Raleigh, NC 13 ft. 30 ft• Rock
30 ft. 35 ft. Unknown
Physical Address,City,and Zip 2L REMARKS
Wake 1723-54-6502
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)
35.767407 N 78.576491 W 09/21/2021
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 ©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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 35 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q2,t00'and 2Q1003 construction to the following:
10.Static water level below top of casing: 27.41 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
6" Solid Stem Auger/Air Hammer 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 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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