GW1-2023-00581_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. O er 14.WATER ZONES
' �
PP FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. &
NC Well Contractor Certification Number 15.OUTER CASING'for multi-cased wells OR LINER rf a livable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. I in.
Company Name 1`6.INNER CASING OR TUBING(geothermal closed-loo "
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 33 ft- 0.75 in. sch 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN '`
Water Supply Well: FROM TO DIAMETER SLOT SIZE: THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 33 ff 43 ft' 0.75 in' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.-GROUT ;
FROM TO MATERIAL- EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft.
Non-Water Supply Well: 30 bentonite pour
ft. ft. ,•
IOMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation "19.SAND/GRAVEL PACK`if a lieable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
30 ft• 43 ft. #2.sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control ,20;DRILLINGLOG attaeli addiiionai'sheets ifnecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 e• 43 u• Silty Sand over saphrolite/Weathered Rock
11/17/2022 TW-1 ft. ft.
4.Date Well(s)Completed: ft. ft.
5.Well Location: ft. ft.
Speedway 6973
ft. ft.
jAN
9 7�
Facility/Owner Name Facility ID#(if applicable) ft. ft.
13960 Capital Blvd. Wake Forest
ft. rt.
Physical Address,City,and Zip
21.REMARKS a,Y
Wake
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) wre a °N4N °aO�•° °
j��,a^g Savices,ou,
36.01271379 78.516918 OPP er /-as'" '' 12/12/2022
%f Date 30W 112 M0 47 LS00'
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or 10Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions: I
9.Total well depth below land surface: 43 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 36 (ft.) Division of Water Quality,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2.25 (in.) 24b.For.Iniection Wells: In addition to sending the form to the address in 24a
Geoprobe DPT above, also submit a copy of this.form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,g ,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013