GW1-2021-06184_Well Construction - GW1_20211025

' i P"ririt Form'
I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I
Todd Muench 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3371 rt. ft. �
ft. ft.
NC Well Contractor Certification Inc.umber 15.OUTER CASING for multi cased iwells OR LINER if a licable
Parratt-Wolff, n FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
WI0501084 16.INNER CASING OR TUBING eothermal closed-loop) _
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) +11
ft. in.
3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER, SLOTSIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public O ft. ft. in.
J Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
J Monitoring ®Recovery
Injection Well:
ft. ft.
I Aquifer Recharge x1 Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
J Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology OSubsidence Control ft. ft.
-I Geothermal(Closed Loop) ril Tracer 20.DRILLING LOG attach additionlil sheets if necessary)
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUmck type, rain
ft. it. tu
4.Date Well(S)Completed: 10/11/21 Well ID#I P-21 - I P-28 fL ft.
Sa.Well Location: ft. ft. 5 Z
William Newton ft. ft. t Uri
Facility/Owner Name Facility ID#(if applicable) ft. ft. 11 ji. 3 7O 1OI3
104 Bayleaf Drive Raleigh, NC
Physical Address,City,and Zip
Wake 21.REMARKS
County Parcel Identification No.(PIN) n 9PT reds
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.91726 N -78.64486 W � ,��
10/13/21
6.Blare)the well(s)oPermanent or J Temporary Signature of Certified Well Contractor Date
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: n
IYes or XJ No with 15A NCAC 02C.0100 or 15A 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 921 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:8 SUBMITTAL INSTRUCTIONS
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-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,use"+^ 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: j
(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& Iniectio n 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.
Forth GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016