GW1-2022-03332_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
CARL CARPENTER 14.WATER.ZONEs t..;..
FROM TO DESCRIPTION
Well Contractor Name ft. ft. [
A - 4475 ft. ft. l
NC Well Contractor Certification Number 15.DUTER CASING for multi-cased"rwells OR LINER if a ticable
FROM TO DIAMETER I. THICKNESS MATERIAL
GEOLOGIC EXPLORATION, INC ft. ft. E
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Company Name 16.INNER CASING OR TUBING" eothermal closed-loop)
FROM TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: 0.0 ft' 20.0 ft. 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): 17.SCREEN
Water Supply Well: FROM TO I DIAMETER; SLOT SIZE THICKNESS . MATERIAL
❑Agricultural ❑Municipal/Public 20.0 "' 35.0 f" 2.0 in.
.010 SCH 40 PVC
ft. ft. in.❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single)❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrl atlon _ 0.0 ft. 15.0 ft' PORTLANDBENTOWE SLURRY
Non-Water Supply Well: ft. ft.
laMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a lieable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 18.0 ft- 35.0 ft• 20-40 FINE SILICA SAND
❑Aquifer Test ElStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionAl sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soit/rock 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-3 2.0 ft- 10.0 ft• RED SILTY CLAY
4.Date Well(s)Completed: Well ID#
10.0 ft- 20.0 ft- TAN SILTY CLAY
Sa.Well Location: 20.0 ff• 35.0 ft. BROWN SILTY SAND
HONEYCUTT CLEANERS tr: rL " -
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAR 14 »
605 NEW BERN AVENUE RALEIGH 27601
Physical Address,City,and Zip
21.REMARKS
WAKE BENTONITE'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 hat/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 ❑Temporary y signing f y fy (j
B si nin this form,/hereby certify lhat the wells 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 ONo copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature oflhe -
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 f6rm. 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 ii(dierent(example-3 cer 200'and 2Q100') construction to the following:
10.Static water level below top of casing: 25.0 (ft) Division of Water Quality,;Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8•0 (in.) 24b. For Infection Wells: In addition 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:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
m 13a.Yield(gP ) Method of test: 24c.For Water Supply&InlectionlWells: In addition to sending the form to
the address(es) above, also submit "one copy of this form within 30 days of
completion of well construction to the,
13b.Disinfection type: Amount: county health department of the county
f
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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