GW1-2021-00664_Well Construction - GW1_20211222

f
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford 14.WATER ZONES .
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased weiIs OR LINER it a' licable
FROM TO DIAMETER THCKNESS MATERIAL
Geological Resources, Inc. ft ft ' in.
Company Name 16.INNER CASING OR TUBING ebtliermal closed400
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 18 rL 2 in. sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc) ft. fL in.
3.Well Use(check well use): 17.:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 18 fL 38 ft. 2 In. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑bri ation 0 ft 14 ft. grout pour
Non-Water Supply Well:
14 ft 16 ft- bentonite pour
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL"PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
16 ft. 38 fA sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG'attach addidoniil`sheets`Ifsecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardens,soil(mck type,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 4 fL Rock/gravel
4.Date Weil(s)Completed: Well ID#
11/10/2021 MW-1 4 rL 18 ft. Orange clay
18 ft. 30 ft. Brown silt clay
5a.Well Location: ft ft
n clay
Quality Food Mart 98 00-0-0000005835 30 3s ft. ft. � I '. _
Facility/Owner Name Facility ID#(if applicable) ft. ft 2
4601 Durham Road, Raleigh, NC 27533 It. ft
Physical Address,City,and Zip 21 REMARKS .4Ja
Wake 0891-54-1410
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)
35.9872400 N 78.6784900 W ( Z6Z
Sign0re of Certified Well CVtractor Date
6.Is(are)the well(s): 21'ermanent 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 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 38 (fL) 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:
unknown Division of Water Resources,Information Processing Unit,
(ft.)
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Hand Auger/ Solid flight auger 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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:
m
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Amount well construction to the county health department of the county where
constructed. f
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013