GW1-2022-05177_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES
Well Contractor Name ^� FROM TO DESCRIPTION
R -`
�=�,„.v � 1,� ft. ft.
A - 4475 ft. ft.
NC Well Contractor Certification Number MAY 3 12022 15.OUTER CASING for multi-cased'wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name n `r1^t' Unq
16.INNER CASING OR TUBING(geothermal closed-loon)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ire//construction permits(i.e.UIC,County.State,Variance,etc.) 0.0 ft- 20.0 ft. 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 fr. 35.0 ft. 2.0 in. .010 SCH 40 PVC
❑GeotlTermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 16.0 ft' PORTLANDBENTONITE SLURRY
[EMonitcring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Storinwater Drainage 18.0 ft. 35.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑GeotlTermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain Linder#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type, chin size,etc.
0.0 1t• 1.0 ft. ASPHALT
4.Date Well(s)Completed: 03/28/22 Well ID# MW-2 1.0 IL 10.0 1t. RED CLAY
5a.Well Location: 10.0 ft. 20.0 ft- BROWN SILTY SANDY CLAY
POPES DRY CLEANERS 20.0 ft- 35.0 ft- TAN SILTY SAND
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1408 CORPORATION PARKWAY RALEIGH 27604 ft. ft.
Physical Address,City,and Zip ft. ft.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 16.0-18.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 48' 01.33" 780 34' 02.23"
N W '`�'' 04/04/22
6.is(are)the well(s)• INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the we/l(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or ONo /SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/fthis is a repair,fill out known well construction it formation and explain the nature ofthe of7his record has been provided to the hell owner.
repair under,21 remarks section or at the back ofdtis 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 35.0 (ft.
1--or multiple wells list all depths ifd Brent(example-3 n 200'and 2@/00')10. ) 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),
lftrater level is abm�e coring,use"+"Static water level below top of casing: (ft. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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 27699-1611
13b.Disinfection type: Amount:
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018