GW1-2022-03340_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD
For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well Contractor Information: !
CARL CARPENTER 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 4475 D. ft.
i.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells .0 LINER if a Gcable
FROM TO DIAMETER; THICKNESS MATERIAL
GEOLOGIC EXPLORATION, INC rt. ". f tin.
Company Name 16.INNER CASING OR TUBING iothermal closed-loop)
FROM I TO I DIAMETER'; I THICKNESS.. _MATERIAL
2.Well Construction Permit#: 0.0 ft• 20.0 1t• 2.0 '" SCH40= PVC
List all applicable trell construction permits(i.e.County,Slate,Variance,etc.)
ft. ft. din.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 1" 35.0 1" 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heat in Coolin Supply) ❑Residential Water SuPPIY(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrl at10n 0.0 ft. 15.0 ft' PORTLAND8ENTONITE SLURRY
Non-Water Supply Well: ---
ft. ft.
MMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 18.0 tt. 35.0 1t' 20-40 FINE SILICA SAND
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soillmck rain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0.0 ft. 2.0 ft. ASPHALT/GRAVEL
11/08/21 MW-1 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
5a.Well Location: 20.0 ft 35.0 1f• BROWN JA*2079
HONEYCUTT CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft
605 NEW BERN AVENUE RALEIGH 27601
ft. ft. i. MAR 1
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:
(ifwell field,one lat/long is sufficient)
350 46' 48.72" N 780 37' 42.71" W C 11/16/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary y g f y fy O (were)B signing this orm,1 hereby certify that the wells was were constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Slandards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy oflhis record has been provided to the well owner.
1J'lhis it a repair,Jill out known spell construction information and explain the nature of the
repair under 421 remarks section or on the back oJ7hi.s 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 nnthiple 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: 35 0 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli ferent(example-3 t@i 200'and 2 a 100') construction to the following:
10.Static water level below to of casing: ( )25.0 ft, Division of Water Quality,Information Processing Unit,
ifwater level is above casing,use"+p" 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: p
(i.e.auger,rotary,cable,direct push,etc.) j
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection 4Wells: In addition to sending the form to
the address(es) above, also submit bne 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.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013