GW1-2021-06182_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Todd MUench 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3371 ft. ft.
ft ft.
NC Well Contractor Certification Inc.mber 15.OUTER CASING for mulfi-cased.Wells OR LINER if ap licable
Parratt-Wolff, r1 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name W 10 5 0 1 0 84 .
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN y'
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
J Agricultural �Municipal/Public Q ft. ft. in.'
J Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) ft. ft in.
J Industrial/Commercial J Residential Water Supply(shared) 18.GROUT
J Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
J Aquifer Recharge 10 Groundwater Remediation
19.SAND/GRAVEL PACK ifa livable
J Aquifer Storage and Recovery )]Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test E)Stormwater Drainage
_I Experimental Technology []Subsidence Control
J Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
J Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM ft ft.To DESCRIPTION color,hardness,soiltrock type,grain size,etc.
4.Date Well(s)Competed: 10/11/21 Well ID#I P-1 - I P-12 ft ft.
5a.Well Location:
William Newton
Facility/Owner Name Facility IDf!(if applicable) ft. ft
104 Bayleaf Drive Raleigh, NC 27615 ft ft. prQrQssing
Physical Address,City,and Zip ft. ft. DWR sect!
Wake 21.REMARKS
County Parcel Identification No.(PIN) I njeeted PetFeFix thFeUgh 1.5" DPT- Fads
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certification:
35.91726 N -78.64486 W �dal wka
10/13/21
6.Is(are)the well(s) Permanent or XI Temporary Signature of Certified Well Contractor ! Date
J
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: rilYes or XMNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:12 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 25 (ft•) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1•5 in.
(• ) 24b.For Infection Wells: In addition to sending the form,to the address in 24a
direct push above,also submit one 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
13a.Yield(gpm) Method of test: 24c. For Water Supply&Iniectilon 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.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016