GW1-2023-02825_Well Construction - GW1_20230420

Pdrit Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Tynan ,.14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2725—A 22 ft, 30 ft. silty sand
ft. It. !
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased'wells OR LINER if a licable
ET FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name WM0501476
16.INNER CASING OR TIIBING eothermal closed-loon)
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS nATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 15 & 2 in 1 SCh40 PVC
3.Well Use(check well use): fL It. in.
Water Supply Well: 17.SCREEN. -
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural FlMunicipal/Public 15 & 30 ft• 2 1A' 0.010 Sch40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft It. is
Industrial/Commercial DResidential Water Supply(shared) 1g.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft, concrete pour
X Monitoring Recovery 3 & 13 ft. bentonite pour through augers
_Injection Well:_—_
Aquifer Recharge ElGroundwater Remediation 19.SAND/GRAVEL PACK if a `lica6le
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 13 ft 30 & #2 silica sand pour through augers
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20;DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Cooling Return) DOther(explain under#21 Remarks) FRonI TO DESCRIPTION color,hardness,soilfrock type,grain sim eta
% tt. See consultant's log
4.Date Well(s)Completed:4/13/22 Well ID# MW 7 ft. ft.
Sa.Well Location:
ft. ft.
Rainbow Cleaners It ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5307 E Six Forks Rd, Raleigh 27609 ft. ft
Physical Address,City,and Zip ft. ft i r1
Wake #1706564113 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.853301 N -78.644778 7e44w _ 4/14/23
6.1s(are)the well(s)oX Permanent or DTemporary Signature ofCe r
d Well Contractor Date '
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this.a repair to an existing well: QYes or XJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ijthls is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 remarks 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 site details or well
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100� construction to the following:
—22 10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service C I enter,Raleigh,NC 27699-1617
'
11.Borehole diameter: 8.5 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
auger above,also submit one 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(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit 'one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction t tthe county health department of the county
where constructed.
'Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016