GW1-2021-02152_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Shawn Robert Davis 4t 14.WATER ZONES
Well Contractor Name JulFROM TO DESCRIPTION
fL fL
4246-A \)L Vrlt 8.71 30.o Ground water
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NC Well Contractor Certification Number pt�y�,.� ,�Zlp p(1 15.OUTER CASING for multi-cased'wells OR'LIlVER if a licable
Froehling & Robertson, �I ll,` ONN FROM TO DIAMETER THICKNESS MATERIAL
ft. I fL in.
Company Name
W M 0501432 1611NNER CASING OR TUBING `eothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft ft. in.
3.Well Use(check well use): fL ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER i SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 fL 30.0 fL 2 in. .01 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 14.8 fL Neat cement Tremie
x Monitoring ❑Recovery 14.8 fL 17.9 fL Bentonite Gravity
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 17.9 f4 30.0 ft well#2 Gravity
❑Experimental Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets it necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
0.0 fL 0.7 fL Gravel over Geotextile
4.Date Well(s)Completed: 6/10/2021 Well ID#WSE-MW-5 0.7 fL 3.3 ft Silty SAND
5a.Well Location: 3"3 ft 8.4 ft Clayey SILT
3119 Associates, LLC N/A 8.4 ft. 12.8 fL Sandy SILT
Facility/Owner Name Facility ID#(if applicable) 12.8 fL 30.0 ft. SAND
600 W. Cabarrus St., Raleigh, NC 27603 fL fL
Physical Address,City,and Zip ft. ft
Wake 1703475257 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:
35.775439963 N -78.646596037 W
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6.Is(are)the well(s)oX Permanent 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 X No with I5A 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 @ 30.0' (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a200'and 2Q100') construction to the following:
10.Static water level below tap of casing: 8.71' 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: 8.25 (in.) 24b.For Iniection 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection 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. 3
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Form G W-t North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016