GW1-2022-07947_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 4475
� I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER ! THICKNESS MATERIAL
e. ft. I in.
Company Name _
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER i THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft- 16.0 ft. 2.0 n' SCH 40 PVC
3.Well Use(check well use): ft. R. l in.
17.SC
Water Supply Well- FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 16.0 fL 26.0 ft' 2.0 1O' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in. i
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 11.0 ft' PORTIANDaENTONITE SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well:
rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMEPHOD,
❑Aquifer Test ❑Stormwater Drainage 14.0 ft. 26.0 ft. 20-40, FINE SILICA SAND
❑Experimental Technology OSubsidence 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/rock type,grain size,etc.
0.0 tt• 1.0 ft• ASPHALT/CONCRETE
4.Date Well(s)Completed: 08/04/22 Well ID# MW-5 1.0 ft. 10.0 ft. BROWN SILTRSAND
5a.Well Location:
10.0 ft' 26.0 BROWN IYPOPES DRY CLEANERFacility/Owner Name Facility ID#(if applicable) tt.
1408 CORPORATION PARKWAY RALEIGH 27604 rt. ft. I
Physical Address,City,and Zip ft. ft. r_t-'J0,GOG
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 11.0-14.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification: ,
35° 48' 00.76" 780 34' 04.99"
N w2'- a`- 08/16/22
6.Is(are)the well(s): TPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this Joan,I herebv certify that the weilt's)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cops'
l f d{is is a repair,Jill out known we//construction information and explain the nature of the of this record has been provided to the we/Lowner.
repair under t'21 rentarks section or on the back oJ'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: 26.0 (ft.)
For nndurple welly list all depths iJ'd&reni(example-3 a 200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
20.0 24a. For All Wells: Original forme,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 water 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 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 400,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test: j
13b.Disinfection type: Amount:
j
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018