GW1-2021-05288_Well Construction - GW1_20210601

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells f
1.Well Contractor Information: REr,r-1 'Lt E
Justin Radford 4 ATEW ONEs�
FROM TO DESCRIPTION
Well Contractor Name 10 rt• 20 ft. gray sandy clay
3270 processing Unit ft. ft. i
InforM.3tion
NC Well Contractor Certification Number p�tVR Sedion 05 eOUTER C'A`SING_fo`i'mulh,caseils�cells OR 4^TNER`if a licatile �,
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. tt. ft. in.
Company Name A&1NNER,CASI1V6`,,,OR7OBING trio�hermal
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: NSA 0 R. 10 ft' 2 '"' SCh 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): A SCREEN-11" ��
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft' 20 ft' 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in'.
❑Industrial/Commercial ❑Residential Water SuPPIY(shared)ed) 8.GROUT , _ :
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 6 ft rOUt
Non-Water Supply Well: 9 pour
(Monitoring ❑Recovery 6 rt. g ft. bentorite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 9.SAND/GRAV.ELYACK(tt°a"tic"able , ?'; r_
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier $ ft. 20 ft. #2 Sand pour
❑Aquifer Test ❑Stormwater Drainage
tt. ft.
❑Experimental Technology ❑Subsidence Control
k2o.DRILLINGttiOG atiacti°additioial,sheetsif neces"sa `' .,' ;?
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soitt o k type, rein size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 0.50 tt• Concrete
4.Date Well(s)Completed: 04��2�2�Well ID#MW-6 0.50 ft. 3 ft. Brown clay with medium sand
3 ft, g ft. Orange brown clay with medium sand
5a.Well Location:
Speedway#8291 0-00-0000035938 s rt 16 fr. Gray with red clay
P y 16 ft• 20 ft. Brown sandy clay
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
100 Broad Street, Fuquay-Varina, NC
Physical Address,City,and Zip 21 RE)17ARKS `„_, a, ._ ;d•r w a.':, ,
Wake 0657923751
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) ( ,
35.598280 N 78.800012 W 4 04/23/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this-form,I hereby certify that the wells)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 AND copy ofthis 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 oneform. SUBMITTAL INSTUCTIONS
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 if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 13.97 (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 Infection Wells ONLY: In addition to sending the form to the address in
611 solid fli ht au er 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g g 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(gp ) 24c.For Water Supply&Injection Wells:
m 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