GW1-2022-03342_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES r
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4475 ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICKNESS MATERIAL
ft. I ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 5.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): R. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in:
S.0 15.0 2.0 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri atiOn ❑Wel Is> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 1.0 ft' PORTtANOEENTONITE SLURRY
TIMonitoring ❑Recovery R. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3.0 ft- 15.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control R. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin sin,etc.
0.0 a• 15.0 l" SANDY RED GRAVEL
4.Date Well(s)Completed: 02/09/22 Well ID# MW-2
5a.Well Location:
CIRCLE K - 2723479
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft.
1900 HIGHWAY 70 EAST GARNER 27529 ft. ft.
Physical Address,City,and Zip ft. ft.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONUE'SEAL-- 1.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 04' 09.98" N 770 01' 27.84" N
G=�')" " 02/18/22
6.Is(are)the well(s): TPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this fitmi,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0100 or 15A NCAC 02C,.0200 Well Construction Standards and that a cow
lJ'dus is a repair,fill out known wel/construction information and explain the nature of the of this record has been provided to the well awner.
repair under t.'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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15.0 (ft.)
Ivrr multiple wells list all depths ifdifjerent(example-3 a 200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
10.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
tf wafer level is above casing,use
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy to�DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.well construction method: AUGER I
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: i
24d. For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh',NC 27699-1 61 1
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018