GW1-2023-01795_Well Construction - GW1_20230223

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Lewis LeFever FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2480 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for
FROM TO muMaF.TF.wRells)O a nbe
K MAT ERI11
Parratt-Wolff, Inc. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 It. 10 It. 0.010 in. sch40 PVC
List all applicable well permits(i.e.County.State,Variance.Injection.etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft- 20 ft. 2 in. .010 SCh40 PVC
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply(single) f. f. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROST TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 8 IL Bentonite Chil Pour
Non-Water Supply Well:
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FRONT TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 8 tr. 20 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DES(RI PTION(coW,hardness,soil/mck type, rain size,etc.I
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
1-18-23 SB/TW-1 ft. -�
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft, g, Ft p S
State Employee Credit Union ft. ft. D
Facility/Owner Name Facility ID#(if applicable) ft. ft. " ' •=n.
4800 Auburn Knightdale Road, Garner
f[. R.
Physical Address.City,and Zip 21.REMARKS
Wake
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal.degrees: 22.Certification:
(ifwcll field one IaUlong is sufficient)
35.690647 N -78.553326 W
S ature of Cent eel&I Con for Date
6.Is(are)the well(s): ❑O Permanent or /Temporary 8v signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 01C.0100 or 1 SA NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
/fthis is a repair,ill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water sapply wells ONLY with the same construction,you can
.submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 4 different(example-A&200'and 1@1001 construction to the following:
10.Static water level below top of casing: none (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
DT-22 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13m.Yield m Method of test, 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013