GW1-2023-00704_Well Construction - GW1_20230113

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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 fL ft.
NC Well Contractor Certification Number L �' „
j15.OUTER CASING for multi-cased wells OR LINER if a tlicable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
JAN A r q, ft. ft. in.
Company Name L V t-
1D_ 16.INNER CASING OR TUBING eothermal closed-loop)
FRONTTO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 9: J v "' - 1
List all applicable;roll construction pertuils(i.e.VIC,County,Slate,I ahi'diice Pls';)?. `'0.0 ft' 20.0 fr' 2.0 '"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 ft. 30.0 ft' 2.0 t"' 1 .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 I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 It- 15.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection V1'e1L•
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test ❑StormwaterDrainage 18.0 ft- 30.0 fr• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION colo-,hardness,soil/rock type,ginin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 30.0 ft. SILTY CLAY
4.Date Well(s)Completed: 12/01/22 Well ID# MW-5 rr. ft.
ft. ft.
5a.Well Location:
IVORY CLEANERS
Facility/Owner Name Facility ID#(if applicable) - --.ft. ---- ft. - - - - - -- - - ---- -
4556 CAPITAL BLVD RALEIGH 27604 ft. ft.
rr. rt.
Physical Address,City,and Zip
WAKE 21.REMARKS
BENTONITE SEAL- 15.0-18.0 FEET
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35° 50' 45.16" N 78° 34' 47.48" W 12/13/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,]hereby certify that the u•ell(s)was(here)constructed in accordance Lriih
7.Is this a repair to an existing well: ❑Yes or MNo !SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction information and explain the nature of the oJYhis record has been provided to the well owner.
repair under#21 retnarkt 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: 30•0 (ft)
For multiple;cells list all depths ifdl(ferent(example-3 n 00'and 2 t@r 100') Submit this GW-1 within 30 days of well completion per the following:
25.0 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 haler lore/is above casing,use"+"
24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 8'0 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loon 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 27699-1611
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
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