GW1-2023-02826_Well Construction - GW1_20230420

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Tynan .14.WATERZONES'
FROM TO DESCRIPTION
Well Contractor Name 34 ft 40 ft. silty sand �
2725-A
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING for multi cased nits)OR LINER if a Gcable
I ET FROM TO DIAMETER THICKNESS MATERIAL
It. ft in.
Company Name WM 05014 76
96.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft 25 ft 2 in• SC1140 PVC
3.Well Use(check well use): ft. & in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 25 R• 40 R• 2 in. 0.010 Sch40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. & in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Itfl ation FROM TO MATERIAL EMPLACEMENT METMOD&AMOUNT
Non-Water Supply Well: 0 ft 3 ft concrete pour
x Monitoring DRecovery 3 ft 23 ft- bentonite pour through augers
—-Injection-Well:— _ --- -_-- __ -_____ __
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
Aquifer Test [3Stormwater Drainage 23 ft 40 ft #2 silica sand pour through augers
Experimental Technology DSubsidence Control ft ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return)
TO DESCRIPTION(color.hardness•soillrock rain sim etc.) Other(explain under#21 Remarks) fa tt
4/13/22 See consultant's log
4.Date Well(s)Completed: Well ID# MW 8 ft ft.
5a.Well Location: ft &
Rainbow Cleaners it
Facility/Owner Name Facility 1D#(ifapplicable) ft ft
5307 E Six Forks Rd, Raleigh 27609 ft ft
Physical Address,City,and Zip ft. ft
Wake #1706564113 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal.degrees:
(if well field,one lattlong is sufficient) 22.Certification:
35.854350 -78.642843
N w 7� 2 % I . 4/14/23
6.Is(are)the well(s)�x Permanent or [:)Temporary Signature ofCe ' ed Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a-repair to_an existing well: [JYes or QNo with I5A NCAC 02C.0100 or ISA NCAC 01C.0100 Well Construction Standards and that a
If this 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#21 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: 40 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierew(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: -34 (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: 8 5 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
auger above,also submit one copy of tliis 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&Infection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016