GW1-2022-07973_Well Construction - GW1_20220826

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER :-14:WATER ZONES'
Well Contractor Name FROM TO DESCRIPTION
A - 4475 ft. ft.
ft. ft.
NC Well Contractor Certification Number 15:'OUTER CASING for multi-ca""wells.OR LINER if no licable,
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. 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,Coun(K State,Variance,etc.) 0.0 ft. 15.0 ft. 4.0 tn' SCH 40 PVC
3.Well Use(check well use): ft. I, in.
17.SCREEN �r '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15.0"' 35.0 ft• 4.0 "' 1 .020 SCH 40 PVC
' ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) A8.GROUT
❑Irrl ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 10.0 ft' PORTLANDBENTONRE SLURRY
❑Monitoring INRecovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL*PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barriel FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 13.0 ft. 35.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑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 I TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft. 1.0 ft. ASPHALT/GRAVEL
4.Date Well(s)Completed: 05/25/22 Well ID# RW-1 1.0 ft. 10.0 It. RED CLAY
5a.Well Location: 10.0 ft. 35.0 ft' RED SILTY CLAY
WESTERN BLVD EXXON ft. ft. ''
Facility/Owner Name - --- - Facility iD#(if applicable)
5201 WESTERN BLVD RALEIGH 27606 ft. ft. AUG 2
Physical Address,City,and Zip ft. ft. ; ;UO Ural
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 10.0-13.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hit/long is sufficient) 22.Certification:
35° 47' 10.03" N 780 42' 46.68" W Z�44_ 06/15/22
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the tvell(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 copy
If dris is a repair,Jill out known well construction information and explain the nature ofthe ofthis record has beenprovided to the well 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 Over'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.)
ror multiple wells list all depilis ifdierent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20.0 (it) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfnater level is above casing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 10.0 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 r
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
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018