GW1-2021-06469_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Todd Muench 14.WATER ZONES-
Well Contractor Name FROM TO DESCRIPTION
3371 ft. ft.
ft. ft.
NC Well Contractor Certification Number
15.OUTER'CASIIVG for in6ffl4w db cased )f!LLffiR,
Parraft-Wolff, Inc. L., THICKNESS MATERIAL
ftCompany NaName �To ft. DIAMETER in. I
W(0501084 -WINNER CASINGORTUSING-firie6th&hud elbsed-1660)
2.Well Construction Permit#: FROM TO DIAMETER _ THICKNESS MATERIAL
l,i.vi all applicable well c-(iii.vii-tictie)iiperntits 0.e.UIC,Counl.l.Stale, lariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
)Agricultural []Municipal/Public 0 ft. ft. in.
]Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) R. ft. in.
3Industrial/Commercial Residential water Supply(shared)
7)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: ft. ft.
3Monitoring DRecovery ft. ft.
Injection Well: ft. rt.
Aquifer Recharge E)Groundwater Remediation
" 'SANDi(GRAVILTACk(ifiiiiii1liksibli),�
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer
Geothermal(Heating/Cooling Return) C30ther(explain under#21 Remarks) FROM ft. TO rL DESCRIPTION(color,hardness,soitlmck type,grain sim etc.)
4.Date Well(s)Completed: 10/11/21 Well ID#IP-21 - IP-28 ft. ft.
5a.Well Location: ft. ft.
William Newton ft. ft. A
Facility/Owner Name Facility ID#(ifapplicablc) ft ft M
104 Bayleaf Drive Raleigh, NC ft. ft
Physical Address.City.and Zip ft
Wake
County Parcel Identification No.(PIN) 'Heeted PetFeFix thFeugh 1.52 DPT- Feds
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one lat/long is sufficient) 22.Certification:
35.91726 N -78.64486 W - 10/13/21
6.Is(are)the well(s)oPcrmanent or )Temporary Signature of'Certified Well Contractor Date
By signing ihislbrin, I hereby cernifi-ihat the we//(s) was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or MNo with I SA NCACO2C.0100 or IjA NCACO2C.0200 Well Con siruenonStandards and thol a
IJ this is a repair.fill ow known well construction information and explain the nature at the copy of dus record has been provided io the well owner.
repair under :21 remarks section or an the hock 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:8 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 35 (fto) 24a. For All Wells: Submit this form Within 30 days of completion of well
bar muluple wells list all depths!1 di*reni(example-36-6200'ond 2(6-000') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing knit,
if iiarerlerel is ahoi:e casing,use** - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1.5 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Direct Push above. also submit one copy of this form within 30 days of completion of well
(i.e.2UgCT.rotary.cable-direct push etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1 13a.Yield(gpm) Method of test: 24c. For Water Supply& Inocc0o'n Wells: In addition to sending the form to
the address(es) above. also submit t one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to I the county health department of the county
where constructed.
Forin GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016