GW1-2022-05176_Well Construction - GW1_20220531

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 1a.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4475 ,L ft. ft.
�'-:-�,,iice�."?'p jq• ,
NC Well Contractor Certification Number S Wg !t { 15.OUTER CASING for multkcaseif e'ells OR LINER if a licablc
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
AAA\/ 9 1 7f177 ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1 f efzv a}k^1 F'i.^.cz'=r 'M Unh FROM TO DIAMETER THICKNESS I MATERIAL
Lisl all applicable ire//construction permits(i.e.UIC,Coanty,Stale l�('�;?e> A 0.0 ft- 14.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 14.0 ft- 24.0 ft' 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 10.0 ft. PORTLANDBENTONnE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTAIETHOD
❑Aquifer Test ❑Stormwater Drainage 12.0 ft' 24.0 ft 20-40 FINE SILICA SAND
❑Experimental Technology El Subsidence Control ft. 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/mck type, min siw,etc.)
0.0 ft. 1.0 ft- CONCRETE
4.Date Well(s)Completed: 03/29/22 Well ID# MW-3 1.0 ". 10.0 ft. RED CLAY
5a.Well Location: 10.0 ft. 20.0 ft- BROWN SILTY SAND
POPES DRY CLEANERS 20.0 ft. 24.0 ft- TAN SILTY SAND/ROCK
Facility/Owner Name Facility ID#'(ifapplicable) ft. ft. I
1408 CORPORATION PARKWAY RALEIGH 27604 ft. ft.
Physical Address,City,and Zip ft. ft.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 10.0-12.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
350 48' 02.51" N 780 34' 03.29"
04/04/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify Thal the we/1(s)was(were)constructed in ac•cordmice triih
7.Is this a repair to an existing well: ❑Yes or I'JNo 15A NCAC 02C.0/00 or 15A NCAC 01C.0200 Well Consiruction Smndardv and that a ropy
/filds is a repair,fill out known well construction itfornmtion and explain the nature oflhe oflhis record has been provided to the we/1 owner.
repair under#21 remarks section or on the back ofthis 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovef in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24.0 (ft.)
(br nmhiple we//s list all depihs ifdierent(example-3 a 00'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
16.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
fu•n[er level it obare casing,use"+"10.Static water level below top of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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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
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,NC 27699-161 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018