GW1-2021-02196_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
V
1.Well Contractor Information:
�UStln Radford In=WATEW,zONEs��
Y FROM TO DESCRIPTION €
Well Contractor Name ft. ft.
3270 A 2011 ft. ft. I
,z
NC Well Contractor Certification Number � 15 OUTER;C�AS1N,G"for�mulh cased'k�Ells'OR�INER°ifa licatile
p1ag5tR�jU FROM ft. TO ft DIAMETER m• THICKNESS MATERIAL
Geological Resources, Inc. ���` ,' On
Company Name " Q '-4:"1NnR(GASING{ORa7 UBING?eothermalfclosed§loo
FROM TO DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 fa 2" in. 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.jSOREEN"
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 It. 20 tr. 2 i"; 0.010 1 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) KZCROUT' F a ti n
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 6 fit. Grout' pour
Non-Water Supply Well:
6 fir. g fit. bentonite pour
oMonitoring ❑Recovery
Injection Well: ft. ft. i
19 SAND/GRAVEL PAGKl if 11`licible
❑Aquifer Recharge ❑Groundwater Remediation
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 8 ft. 20 ft. Sand pour
❑Aquifer Test ❑Stormwater Drainage
fit. ft.
❑Experimental Technology ❑Subsidence Control
00.,DRILL^INISVOGt(T ch,a-'ddiiional.'sheet"slif necessa,. w
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fit. 1 fit. Red clay coarse
06/14/2021 MW-12 1 fit. 4 ft. Light tan coarse
4.Date Well(s)Completed: Well ID#
4 fir. 5 fit. Light brown fine
5a.Well Location:
600 Glendon Way Property n/a 5 f[: 10 fir. Light brown/gray fine
10 17 Light brown silt
Facility/Owner Name Facility ID#(if applicable) 17 fir' 20 fr• Brown/gray SIIt
600 Glendon Way, Cary, NC ft. ft.
Physical Address,City,and Zip ,
21, E11tAR1ZS
Wake 0734-75-7973
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
35.799268 N 78.871794 W 0 06/18/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(S): ©Permanent or ❑Temporary By signing this form,I hereby certify ghat 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 END 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 ofthis 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: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdfferent(example-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: n/a (ft.) Division of Water Resources,Information Processing Unit,
If water level it above casing,use"+" 1617 Mail ServicelCenter,Raleigh,NC 27699-1617
11.Borehole diameter: 611 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
6" Solid Fli ht Au er 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g 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 ServiceICenter,Raleigh,NC 27699-1636
13a.Yield(gp ) 24c.For Water Supply&Injection Well's:
m Method of test: 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