GW1-2023-01796_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:
Lewis LeFever F4.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2480 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ticable
FROM TO DIADI F.TP:R THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. I ft. in.
Company Name 16.INNER CASING OR TUBING eotherraal closed-loop)
FROM I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 It• 0.010 i" sch40 pvc
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS ,MATERIAL
❑Agricultural ❑Municipal/Public 5 It- 10 ft. 2 in. .010 sch40 pvc
:lGeothermral(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) GROUT
FROM TO MATERIAL EMPLACENIENT NIETHOD&AMOUNT
❑Irri ation 0 It. 3 ft- Bentonite Chil Pour
Non-Water Supply Well:
ft. ft.
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO NIATERI,tL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fr. ft.
3 15 #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
28.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock is e,grain size,etc.)
❑Geothermal(Heatin Cooting Return) ❑Other(explain under#21 Remarks) ft. ft.
ft.
ft.
Date Well 1-18-23s)Completed: Well ID#SB/TW-2 ft. ft.
5a.Well Location: ft. ft.
State Employees Credit Union ft. ft. - I .
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
4800 Auburn Knightdale Road, Garner
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 lat/long is sufficient)
35.690333 N -78.553368 W
[ature of Certified V7ell CCAIMCIOT Date
6.Is(are)the well(s): ©Permanent or emporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo copy of this record has been provided to the well owner.
Ifthis 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 15 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(ecamplr 3fd 200 and 2(4,100') construction to the following:
10.Static water level below top of casing: 5 (ft.) Division of Water Resources,Information Processing Unit,
4 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
13a.Yield(gym) Method of test: 24c.For Water Supply&Injection Wells:
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