GW1-2022-03331_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For Internal Use ONLY: {;
This form can be used for single or multiple wells
1.Well Contractor Information: " -
t e .
C '14.WATER
ARL CARPENTER
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 4475 ft. ft.
NC Well Contractor Certification Number 35C OUTER CASING for multi-cased wells OR LINER if 5 Gcable
FROM TO DIAMETER _ _THICKNESS. MATERIAL
GEOLOGIC EXPLORATION, INC ft. ft.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS _ MATERIAL
2.Well Construction Permit#: 0.0 ft' 20.0 1" 2.0 in. SCH 40 PVC
List all applicable well construction permits(i.e.County,Stale,Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 97.SCREEN
Water Supply Well: FROM . TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 ft' 35.0 "' 2.0 in'i .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.
❑Irrl ation _ 0.0 ft. 15.0 ft' PORTLAND aENTONnE SLURRY
Non-Water Supply Well: ft. ft.
loMonitoring ❑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 18.0 ft- 35.0 It- 20-40 FINE SILICA SAND
❑Aquifer Test ❑Stormwater Drainage ft. It.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0.0 ft. 2.0 ft. ASPHALT/GRAVEL
11/08/21 MW-4 2.0 ft. 10.0 ft.
RED SILTY CLAY
4.Date Well(s)Completed: Well ID#
10.0 tt• 20.0 ft- TAN SILTY CLAY
5a.Well Location:
20.0 ft 35.0 ft' BROWN SILTY SAND
HONEYCUTT CLEANERS-
ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
605 NEW BERN AVENUE RALEIGH 27601
ft. fr.
Physical Address,City,and Zip 2L REMARKS
WAKE BENTONIfE SEAL 15.0-18.0 FEET
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one tat/long is sufficient)
350 46'48.72" N 780 37' 42.71 W C-a- � 11/16/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify thdl the well(s)was(were)constructed in accordance
wilh 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 ONo copy oj'lhis record has been provided to the we//owner.
If this is a repair,Jill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back qf 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 saute construction,you can
submit one jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 35.0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJfereni(example-3@200'and 2@100') construction to the Following:
10.Static water level below top of casing: 25.0 (ft.) Division of Water Quality,Information Processing Unit,
Ifwaler level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8•0 (in.) 24b. For Infection.Wells: In additlion to sending the form to the address in 24a
AUGER above, also submit a copy of this'form within 30 days of completion of well
12.Well construction method: construction to the following: y
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Unileiground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
L
13a.Yield(gpm) Method of test: 24c.For Water SuuDly&Injectioi Wells: In addition to sending the form to
the address(es) above, also submit lone 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.
Revised Jan.2013 Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality
i