GW1-2023-00703_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 4459
ft.
NC Well Contractor Certification Number I&OUTER CASING for multi-cased Wells)TOB�L AiLable)
FROM TO TER T.,Wapi I MATERIAL
GEOLOGIC EXPLORATION JAN 1 2023
Company Name ft ft. in.
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,County,State,Variance,etc.) 0.0 ft- 20.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.Water Supply Well: FROM SCREEN TO DIAMETER SLOTSIZE THICKNESS
[]Agricultural ElMunicipal/Publie 20.0 It' 30.0 ft' 2.0 in. .010 SCH 40 PVC
DGeothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft.
OIndustrial/Commercial ElResidential Water Supply(shared) 18.GROUT
01rrigation E]Wells>100,000 GPD FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 15.0 ft' PORTLAND BENTONITE SLURRY
TlMonitoring DRecovery ft. ft.
Injection Well: ft. ft.
El Aquifer Recharge oGroundwater Remediation
19.SAND/GRAVELTACK if applicable)
DAquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test DStormwater Drainage 18.0 ft 30.0 ft. 20-40 FINE SILICA SAND
0 Experimental Technology EI Subsidence Control
DGeothermal(Closed Loop) ElTracer 20.DRILLING LOG(attach additional sheets if necessary)
oGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.)
0.0 " 30.0 ft SILTY CLAY
4.Date Well(s)Completed: 12/01/22 WeIIID# MW-4 ft.
5a.Well Location:
IVORY CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4556 CAPITAL BLVD RALEIGH 27604 ft. ft.
Physical Address,City,and Zip ft. ft.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 15.0-18.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 50' 45.16" 780 34' 47.48"
N W 12/13/22
6.Is(are)the well(s): [EPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this forte,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or [ENo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that 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 tinder#21 remarks section or on the back of ihisforni. 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: 1 30.0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths it different(example-3@200'and 2@100')
2S.0 24a. For All Wells: Original form 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
cut
f county
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department the '6 rit,al 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20 18
i