GW1-2021-05302_Well Construction - GW1_20210615

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or mtdtipic%yells
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1.Well Contractor Information:
14;.NVATEIYZONE5 s
Gray Sherrill �+,� FROM TO DESCRIPTION
1Vcll Contractor Namc S 445 ft. 450 ft 17 gpm
2220—A ! ray 0 2021 455 ft. 460 ft. 83 gpm
NC Wcll Contractor Certification Nunt6cr J 1 AS.�OUTER,CASING forfin lh-rased-111)'!ORLiNER'(f ti` hcable
r ll'a�yr1M?"��ry�n � t)s�lt FROM rt. TO R DIAMETER in. THICKNESS MATERIAL
McCall Brothers Inc. i • .,.o
CANNEK.CASING:OR''TUBING"'"coth'ccimeCclOscd400 r r
Company Name
WS0500156 FROM TO DIAMETER . THICKNESS MATERIAL
2.Well Construction Permit ft: 0 ft. 63 ft. g in. 375 galvanized steel
List all applicable hell construction permits(i.e.Courant Stare.Variance.etc.) (t. ft. in.
3.Well Use(check well use): 47.SCREENt.
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. I ft. J in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑ tduslrial/Conmtercial ❑Residential Water Supply(shamed) i'18.GROUT
1/� FROM TO MATERIAL EMPLACEMENT METHOD A AMOUNT s
'gym ation • 0 ft 63 ft cement pumped it in
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation 19 SAND/GRAVEL PACK if i liable
❑Aquifer Storage and Recovery ❑Saliniq'Barrier FROM ft. TO ft. MATERIA L. FAIPLACEM ENT METHOD
❑Aquifer Tcst ❑Stonmyatcr Dminagc
ft. rt. i
❑Experimental Technology ❑Subsidence Control
: DRILLING LOG attach n'dditirinat sheets if necessun
❑Geodaemal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hanlncer,sniUrock type.grain An.etc.)
❑Gcothcnnal(Hcatin Cooling Rctum) ❑Outer(explain wider B21 Rcnuadcs) 0 ft. 18 ft. over burden
2021 18 ft. 30 ft' Brown dirt
4.Date Well 5/21s)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/Omicr Nanic Facility lD#(if applicable) ft. ft.
wake county government, facility
Plwsical Address.City.and Zip raj 212+REt11ARKS
willow springs NC 27592 �+A n/a
County Parccl identification No.(PIN)
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well ficid.one lat/long is sufticiciu)
35035'04.722" N 78040'38.7624" s/z1/zozl
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Signature of Ccnificd Wcll Conimcior Datc
6.iS(are)the well nnanent Or ❑TCrnpOrar} By signing this form.1 hereby certify that the ii'eldfs)was(irere)constructed in accordance
ii•ith 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 D•NO copy of this record has been provided to the urll omher.
1f this is a repair,fill out knouvu well comtnucrion infonnation and explain the nature of the
repair under N21 remarks section or nit 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•irater supply wells ONLY ivith the same construction.you can
submirone funn. 24.Submittal instructions:
9.Total well depth below land surface: 500 (ft) 24a. For All Wells: Submit this Conn within 30 days of completion of well
For multiple ieedls list all depths ifdperent(erangde.3@200'alit/1Ca100') construction to the following:
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10.Static water level below top of casing: 30 (ft.) Division of Water Quality,Information Processing Unit,
If!rater level is above cursing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
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8 24b.For.infection Wells: In addition to sending die form to the address in 24a
above, also submit a copy of this Conn within 30 days of completion of well
12.Well construction method: air rotary construction to the following:
(i.c.augm rotary,cable,direct push cicJ
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 Suooly&Genthcr•mal Wells: hi addition to sending tlic fomi to
the address(cs) above. also submit one copy of this fomi within 30 days of
chlorine Amount: 22 ounces completion of well construction to the county health department of the 6intA
136.Disinfection type: where constructed.
Fomi GW-1 North Carolina Dcpartmicnt of Environment and Natural Resources-Division of WalciQuality Reused Jan.2013