GW1-2023-00874_Well Construction - GW1_20230118

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER �--r 14.WATER ZONES
Well Contractor Name t{,,,,J FROM TO DESCRIPTION
ft. tr.
A - 4475 JAN 1 g 2023 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
O "'�� FROM TO - DIAMETER THICKNESS MATERIAL
GEOLOGIC EXPLORATION 10mir, � t r.••°' Und
� ft. I rt. I in.
Company Name _
16.INNER CASING OR TUBING eothcrmal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
list all applicable trees construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 1 25.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 fc• 35.0 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 atlon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT M ETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 21.0 ft' PORTLANDBENTONRE SLURRY
Monitoring El Recovery
Injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 23.0 ft- 35.0 It- 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,hardness,soil/rock type, nin size,etc.)
0.0 ft. 1.0 ft GRAVEL
4.Date Well(s)Completed: 1 0/03/22 Well ID# MW-2 1.0 It- 10.0 It- RED CLAY
5a.Well Location: 10.0 ft' 20.0 ft' BROWN CLAY
VIP CLEANERS 20.0 ft• 35.0 ft- TAN SILTY SAND
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
3801 SOUTH WILMINGTON STREET RALEIGH 27603 ft. ft.
Physical Address,City,and Zip ft. I ft.
WAKE 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-21.0-23.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell held,one lat/long is sufficient) 22.Certification:
35e 43' 39.56" 780 38' 57.59"
N W ._.� 10/31/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing This form,1 hereby certify that lite well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standardv and that a copy
1/Ili&is a repair,fill out known well construction in/brnnation and explain the nature of the ofthis record has been provided to Cite trell owner.
repair under 1121 remarkv section or on 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 info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 35•0 (ft.)
For tathip/e hells list all depths li different(example-3 a 200'and 2 rr/00') Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: 23.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If tracer level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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-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
13:I.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018