GW1-2021-02200_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Todd Muench
@ 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3371-A IuL 2021 7 ft- 50 rt• wet sand and silt
,Z 1 rt. rt. �
NC Well Contractor Certification Number l VIA 15.OUTER CASING for multi-cwed.weHs OR LINER if a Gcable
Parratt-Wolff, Inc. atAn ProcessIn`� FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name Y t
16.INNER EASING OR TUBING eothermall closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
l,i.st all applicable well construction permits(i.e.UIC,(bunts,State, Variance,etc.) 0 it. 40 I'L 2 in' SCh 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 40 ft- 550 ft, 2 i"' .010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 40 ft. ,"•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 rt• 34.5 rt' Portland Cement Tremie
I'Monitoring ❑Recovery 34.5 ft- 37 ft' Bentonite Chips Gravity
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK.(if a icable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 37 ft- 50 ft- #1 Filter Sand Gravity
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attacti additional'Atiets'if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,spill o k type,gritin sbe,etc.
0 ft. 10 ft- Tan/grey sand with silt
4.Date Well(s)Completed: 7/2/21 Well ID# MW-18D 10 ft- 25 rt• Lt. yellow/orange silt and sand
5a.Well Location: 25 ft' 55 ft- tan/white/grey silt and sand
Speedway LLC. 0001246 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2808 US HWY 70 Business East, Clayton, NC rL ft.
Physical Address,City.and Zip ft. ft.
Wake 1740204987 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one]at/long is sufficient) 22.Cer' on:
35.675438 N -78.520793 w 7/7/2021
6.Is(are)the well(s): (lPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hv signing this.1brnn,I herehv cenifv that the well(s)was(were)consinucted in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A N<'A('02('.0100 or l5A N('A('02('.0200 Well('onstntction Stan clards and that o cops
lJ this is a repair,Jill an knots nit ell construction information and explain the nature oJ'rhe q/this record has been provided to the n-ell corner.
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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Y,ou may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 50 (ft.)
Pbr multiple wells list all depths tfdii&rent(example-3@200'and 2@ 100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR);
10.Static water level below top of casing: 7 (ft.) Information Processing Unit, 1617,MSC,Raleigh,NC 27699-1617
1J'water level is above casing,use
11.Borehole diameter: 8 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
L1
Program, 1636 MSC,Raleigh,N027699-1636
12.Well construction method: Hollow Stem Auger
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger.rotary.cable,direct push.etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d. For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 C.Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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