GW1-2023-00700_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 4459 I' _.. ,�
_k l+C�.v lV.• :1x.
ft. ft.
NC Well Contractor Certification Number ` '1
JAN j 2O2J IS.OUTER CASING for multi-cased wells OR LINER ifa slicable
GEOLOGIC EXPLORATION
FROM TO DIAMETER THICKNESS MATERIAL
- ''• ft. ft. in.
Company Name
16.INNER CASING OR TUBING eother at closed-lop
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable IreH construction permits(i.e.UIC,County,State,Variance,etc) 0.0 f`• 5.0 ft- 2.0 in- SCH 40 PVC
3.Well Use(check well use): ft. fr. in.
17.
Water Supply Well: FRONT REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/PLiblic 5.0 ft' 15.0 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. 3.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Agitifer Test ❑Stormwater Drainage 4.0 f`• 15.0 f`• 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 421 Remarks) FROM TO DESCRIPTION color,hmdness,soivrock type,gmin size,etc.
0.0 ft 0.5 f` CONCRETE
4.Date Well(s)Completed: 11101122 Well ID# MW-4 0.5 f` 15.0 f` SILT
ia.Well Location:
rt. fr.
ZEBULON CLEANERS
Facility/Owner Name Facility ID#(if applicable)
131 VANCE STREET ZEBULON 27597 ft. ft.
Physical Address,City,and Zip ft. ft.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-4.0 FEET
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 49' 19.77" N 78e 18' 41.22" W i 11/02/22
6.Is(are)the well(s): MPermauent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing this form,I hereby certify that the trell(s)was(mere)constructed in accordance trah
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Slandards and that a copy
ry'this is a repair,fill out known n,e/l construction h formation and explain the nature of the ofthi.s record has been provided to the well owner.
repair under 421 retnarks section or an the back of 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 into
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: 15.0 (ft.)
kbi-nuilliple spells list all depths lfdifferent(example-3@200'aml 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 8•0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lflrarer level is above casing,use"+'• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
$.0 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) 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
13:1.Yield(gpm) Method of test: Penn it Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018