GW1-2023-00888_Well Construction - GW1_20230118

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
f,..'b ."� `� 0
A - 4475 kit, � ft. rt.
NC Well Contractor Certification Number J H" •� $ Z023 15.OUTER CASING for multi-cased wells OR LINER if a able)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name {+rl im` 1 �f'"Y?�?+�?�0ull~
lih�0 y 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable vel/construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft. 25.0 f[. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 ft• 35.0 ft. 2.0 "' 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 TO MATERIAL EMPLACEMENT METHOD B AMOUNT
Non-Water Supply Well: 0.0 ft. 21.0 ft. PORTLANDBENTONITE SLURRY
I!lMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer'Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PAC K i(a licable
❑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
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Rem FROM TO DESCRIPTION color,hardness,soil/ivck e, rain size,etc.
arks)
0.0 ft• 1.0 ft• TOPSOIL
4.Date Well(s)Completed: 10/05/22 Well ID# MW-4 1.0 ft. 10.0 ft. RED CLAY
5a.Well Location: 10.0 ft' 20.0 ft. BROWN CLAY
VIP CLEANERS 20.0 ft• 35.0 R• TAN SILTY SAND
Facility/Owner Name Facility ID#(ifapplicable)
3801 SOUTH WILMINGTON STREET RALEIGH 27603
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:
(ifwell field,one]at/long is sufficient) 22.Certification:
350 43' 39.56" N 78° 38' S7.59" W i ;_` --�' 10/31/22
6.1s(are)the well(s): (TPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 Hereby ceritfy ilia''lie ire//(s)vas(were)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 ihat a copy
/fthis is a repair,Jill out known yell eonsiraciion ii?fbrnration and explain the nature of the of this record has been provided to the yell owner.
repair under B21 remarks section a•on the back of this Jorm.
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.)
Far nahiple irells fist all depths'IJ'diJJerent(example-3 rr 00'and 2@106') Submit this GW-1 within 30 days of well completion per the following:
23.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
J'u Static water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
/f 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
(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:
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018