GW1-2022-03344_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES
Well Contractor Name FROM ft. TO ft. DESCRIPTION
A - 4475 B. a.
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. I In.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc) 0.0 ft- 5.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): fr. fr, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft' 15.0 rt• 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fr. to
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 1.0 ft. PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3.0 ft- 15.0 tt. 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 I TO DESCRIPTION color,hardness,soiVrock type,grain size,etc.
0.0 ft 15.0 ft SANDY RED GRAVEL
4.Date Well(s)Completed: 02/09/22 Well ID# MW-4
5a.Well Location: ft. it.
CIRCLE K - 2723479. ft. ft.
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. f �V�/i nA/t ,
1900 HIGHWAY 70 EAST GARNER 27529 ft.
Physical Address,City,and Zip
rt. ft.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 1.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
350 04' 09.98" N 770 01' 27.84" W
02/18/22
6.ls(are)the well(s): (EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,1 hereby c•erlify that the well(s)was(were)c•ons•trucled in accordance with
7.Is this a repair to an existing well: ❑Yes or [!5No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
I/'lhis is a repair,fill out known well construction information and explain the nature of the of This record has been provided to the we'll owner.
repair under!!21 remarks section or on the hack 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 Ro provide additional well construction info
construction,only I GW-1 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. (ft)
For nnrltiple welts list all deplhs ifdii ferenl(example-3 rev 200'and 2@100') Submit this GW-I 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
If waler level is above casing,use i
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy toiDWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh i,NC 27699-161 1
i
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018