GW1-2023-00875_Well Construction - GW1_20230118

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER _ 14.WATER ZONES
v FROM TO DESCRIPTION
Well Contractor Name Z ba °"i, t
ft. ft.
A - 4475 JAN ] (�`� rt. It.NC Well Contractor Certification Number * 8 20`�
15.OUTER CASING for multi-cased wells OR LINER if a licablc
GEOLOGIC EXPLORATION jn#oma iz�n hf :,5w�)ng Una FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name '11=I ?
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) 0.0 ft- 25.0 ft- 2.0 "' I 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 25.0 ft' 35.0 f" 2.0 '"• .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wel Is> 100,000 GPD FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 21.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
•Aquifer Test ❑Stormwater Drainage 23.0 ft• 35.0 ft- 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 color,hardness,soil/rock type, min size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft- 1.0 ft. ASPHALT
4.Date Well(s)Completed: 1 0/03/22 Well ID# MW-1 1.0 ft- 10.0 ft. RED CLAY
5a.Well Location: 10.0 ft' 20.0 B- BROWN CLAY
VIP CLEANERS 20.0 ft- 30.0 ft- GRAY CLAY
Facility/Owner Name Facility ID#(if applicable) 30.0 ft- 35.0 ft- TAN SILTY SAND
3801 SOUTH WILMINGTON STREET RALEIGH 27603 ft. ft.
Physical Address,City,and Zip
ft. 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:
(if well field,one lat/long is sufficient) 22.Certification:
350 43' 39.56" N 780 38' 57.59" W � CD - 10/31/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the nPell(s)Bras(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 Standards and dial a copy
lJ7his•is a repair,Jill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section at-on the back of7his 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-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: 35.0 (ft)
For nudtiple wells list all depths tfdijjJ,rent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the fallowing:
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
Ifsra[er 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
(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 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018