GW1-2023-00702_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
{T y77
A - 4459 «_.. .. ...
ft. fr.
NC Well Contractor Certification Number JA N d 2OZ3 15.OUTER CASING for multi-cased wells OR LINER if a tlicahle
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
-__ _ t t.•.v ft. ft. in.
Company Name
t,_a,9.•�,L�:J'"•'�: 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well c•onstruclion permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 5.0 ft- 2.0 t"' I SCH 40 PVC
3.Well Use(check well use): ft, ft. in.
17.SCREEN
Water Supply Well: -
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 It- 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) lS-GROUT
❑Irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 n' 3.0 ft' PORTLANDBENTONITE SLURRY
ISMonitoring ❑Recovery
injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a IicahLe
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft- 15.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control fr. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTIONcolor,hardness,soil/mck type, rain size,etc.
0.0 ft. 0.5 ft- CONCRETE
4.Date Well(s)Completed: 10/31/22 Well ID# MW-2 0.5 ft• 15.0 ft• SILT
5a.Well Location:
ZEBULON CLEANERS
Facility/Owner Name Facility lD#(ifapplicable) ft. ft.
131 VANCE STREET ZEBULON 27597 ft. ft.
Physical Address,City,and Zip fr. ft.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
350 49' 19.77" N 780 18' 41.22" W �/�e
11/02/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this firm,I hereby certify that the we/l(s)was(mere)constructed in accordance u'uh
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and ilia/a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided 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
constnuction,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: 15.0 (ft.)
hor nudlip/e wells list all depths ifd erenl(example-3@200'and 2 rr 100')10. Submit this GW-1 within 30 days of well completion per the following:
8.0 24:t. For All Wells: Original form to Division of Water Resources (DWR),
Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfmaterlerelisaborecasing,use"+"
11.Borehole diameter: 8.0 (in,) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (!UC)
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 27699-161 1
13b.Disinfection type: Amount:
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018