GW1-2021-02074_Well Construction - GW1_20210702

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: Print Form
1.Well Contractor Information:
Shawn Robert Davis [RECEIVED 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
O 2�21 20.73 ft• 49.3 ft Ground water
4246-A J U L ft. rL
NC Well Contractor Certification Number 9 Unit
rifOrrrat/0n Processing 15.OUTER CASING for multi-cased wells OR LINER ita livable
Froehling & Robertson, Inch. DWR$edo" FROM TO DIAMETER THICKNESS MATERIAL
in.
Company Name
W p O G 001 A,t 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ft J 44 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 19.3 fa 49.3 ft' 4 1O' .01 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
01tri aeon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 14.3 ft- Neat cement Tremie
❑Monitoring Recovery 14.3 ft- 17.3 ft' Bentonite Gravity
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL'PACK if a livable '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT MEETHOD
❑Aquifer Test ❑Stormwater Drainage 17.3 IL 49.3 ft- Well#2 Gravity
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.
0.0 ft- 5.5 ft- Clayey Silt
4.Date Well(s)Completed: 6/3/2021 Well ID#WSE-PTW-1 5.5 ft- 6.5 ft. Coal
5a.Well Location: 6.5 ft. 10.5 ft. Silty Clay
Raleigh Union Station/City Of Raleigh N/A 10.5 ft 39.0 fL Silty Sand
Facility/Owner Name Facility ID#(if applicable) 39.0 ft. 49.3 ft. Weathered Rock
510 W. Martin St., Raleigh, NC 27601 ft. ft.
Physical Address,City,and Zip
rt. ft.
Wake 1703476921 21.REMARKs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.77608196 N -78.64634139 -s1 A
6.Is(are)the well(s)oPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: ❑Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 @ 49.3' (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: 20.73' (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: 0.25 (in,) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger above,also submit one 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,jUnderground 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&lniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016