GW1-2021-00662_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Sam Bowers FROM
ZONES DESCRIPTION `
Well Contractor Name ft. ft.
3220-A ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if ap cable)
FROM I TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. I iin.
Company Name 16.INNER CASING OR TUBING 'eothermal closed-loop),'
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: NSA 0 it. 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): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public 10 fl. 20 ft' 2 i"' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply(single) ft. ft. in.
� � g PP Y) PP Y( � S )
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT 11 1, 1 1 r;
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 6 ft rout our
Non-Water Supply Well: 9 p
g ft. g it. bentonite pour
19Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK'if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
9 20 #2 sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addifioial sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer r3f-
TO DESCRIPTION color,hardness,soiltrock s etc.
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 3 ft. Rocky backfill
08/24/2021 MW-2,3,4 17 ft. Red clay
4.Date Well(s)Completed: Well ID# 20 ft. Red/tan clay
Sa.Well Location: ft.
Webb's Mini Mart 0-00024760 ft ft �.z. =
Facility/Owner Name Facility m#(if applicable) --
ft. ft.
900 Poole Drive, Garner, NC
Physical Address,City,and Zip 21.REMARKS
Wake 1710-38-5288 tTOPMATP rx '_
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)
35.695698 N 78.616966 `,lr 10/19/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)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 E]No copy of this 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: 3 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 one form. 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: 11 .39 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
6" Solid Fliryht au er 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: y 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(gpm) Method of test: 24c.For Water Supply&Injection Wells:
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