GW1-2021-04670_Well Construction - GW1_20210517

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WELL CONSTRUCTION RECORD For htemal Use ONLY:
This Conn can be used for single or multiple wells
1.Well Contractor Information:
�,� ti"
Gray Sherrill Apo. \ si FROM TO DESCRIPTION
Well Contr ictor Name y _ an 445 ft- 450 fl. 17 gpm
2220-A �Ui L 2116� 455 ft. 460 ft 83 gpm
NC 1Vc11 Contractor Certification Number 1
+.IS OUTER.CASING for.'multt rasidaiclls'lOR-DINER (f u` hcnble
e. �rr+t,P`3';.ng 1�nit FROM TO DIAMETER T(IICKNESS \1ATERWL
McCall Brothers, Inc. �et$Oilii3�'O"n r_��1?flat fl. ft. in.
Company Nante °° 16 4NNER�CASING:OR TUBING`'('6fhcF&Al*cl6sed400)
WS0500156 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 It. 63 fl. 8 in. 375 galvanized steel
List all applicable well construction permits(i.e.Comity.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): Id SCREEN,
Water Supply Well: FROM I TO I DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
ft. ft. in.
❑Agricul(uml ❑MunicipaVPublic i
❑Gcolhennal(Healing/Cooling Supply) OResidcntial Water Supply(single) ft. ft. in.
td ustrial/Conmicneial ❑Residential Water Supply(slurred) 18:iGROUT
FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
X 'Rion 0 fl 63 ft cement
pumped It in
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recover•
Injection Well: ft. ft.
❑Aquifcr Recharge ❑Ground%atcrRcmediation ?19s.SAND/GRAVEL PACK(ifibrilkablil -
❑Aquifcr Storage and Recovery ❑Salinity Barrio FROM ft. TO ft. MATERIAL. EMPLACFMENTMErHOD
❑AquifcrTcst ❑SlomntalcrDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
30:`DR[LLING LOG attach'nPdduiorial'shcets(tocc`cccan :='
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color.harincct.soiUmck ii e.grain Aux.etc.)'
❑Geothermal(Hcaliti Cooling Return) 001her(explain under#21 Remarks) 0 ft. 18 ft- over burden
5/21/2021 18 ft' 30 ft. Brown dirt
4.Date Well(s)Completed: 30 ft- 50 ft- dirt and sand mix
5.Well Location: 50 ft. 63 ft- black rock
3355 NC highway 42 n/a 63 ft- 500 ft, granite
Facility/Omier Name Facility lD#(if applicable) ft. ft.
wake county government, facility ft. n.
Ph sisal Address.City.and Zip n� 21:RENIARKS v�
willow springs NC 27592 n/a
County Parccl identification No.(PIN)
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if e•ell field,one lat sufficient)
long is sucient) 22.Certification:
35035'04.722" N 78040'38.7624" W 6 CA,4_tj 5/22/2021
Signature of Certified Well Contractor Date
6.Is(arc)the welll1&rmancnt or ❑Temporary By signing this join.I hereby certify that the ivell(s)was(were)emnstnucted in accordance
iritn 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards mid that a
7.Is this a repair to an existing well: ❑Yes 00 NO copy of this record hat been provided re the well miner.
If this is a repair,fill out knowrn Well Cmistnucrion information and explain the native of the
repair under#21 remarks section or nit the back of this jorm, 23.Site diagram or additional well details:
You may use the back of this page to pro%ide additional well site details or well
8.Number of wells constructed: 1 conslmclion details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY irith rile sane construction..Volt can
sulnuit one font. 24.Submittal instructions:
9.Total well depth below land surface: 500 (ft) 24a. For All Wells: Submit this'form within 30 days of completion of well
Far i alriple ireUs list all depths ff different(ecample•3@200'and 2@ 100') constniclion to(Ile following:
10.Static water level below top of casing: 30 (ft.) Division of Water Quality,Information Processing Unit,
If%carer level is above casing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
f
11.Borehole diameter: 8 241).For Injection Wells: In addition to sending tlic.fonn to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
air rotary constaiction to the follotrin
1Z.Well construction method: g: i
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 115 Method of test, air lift 24c.For Water Sunnlr&Gentile i A Wells: in addition to sending the form to
Ilic addrcss(cs) above, also submiUone copy of this form within 30 days of
I36.Disinfection type: chlorine Amount 22 ounces completion of ivell construction to the county health department of the county
where constricted.
Form GAV-I North Carolina Department of Em•ironnicut and Natural Resources—Division of Water Quality Revised Jan.2013