GW1-2023-02827_Well Construction - GW1_20230420

I '
F_.Print Form .
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
I.Well Contractor Information:
Mike Tynan K WATERZONES.
Well Contractor Name FROM TO DESCRWFION
2725_A 11 ft 20 ft clayey sand
ft ft.
NC Well Contractor Certification Number I 15._OUTER-CASING for cased,wel{s OR LINER if a livable
ET FROM TO DIAMETER I THICKNESS MATERIAL
ft ft. io.
Company Name 16.INNER CASING OR TUBING eothermal closed400 .
W 0501476
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permlis(i.e.UIC,County,State,Variance,etc.) 0 ft 5 ft 2 1O 1 SCh40 PVC
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 5 ft- 20 ft- 2 in- 0.010 Sch40 PVC
Geothermal(Heatingicooling Supply) 0Residential Water Supply(single) ft. ft in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 3 It. concrete pour
x Monitoring Recovery 3 ft 4 ft- bentonite pour through augers
Injection Well:__ ___ --.— -
- _ - It. fl — -
Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK ifs livable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 4 ft 20 ft #2 silica sand pour through augers
Experimental Technology Subsidence Control It, ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additions{sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks FROM TO DESCRIPTION colon hardness,soillrock type,%m6n sin,etc.
ft. ft, See consultant's log
4.Date Well(s)Completed:4/11/22 Well m# MW 6 & ft.
5a.Well Location: ft. ft
ft ft,
Rainbow Cleaners 'L
Facility/Owner Name Facility ED#(ifapplicable) ft ft
5241 E Six Forks Rd, Raleigh 27609 %
Physical Address,City,and Zip ft ft
Wake #1706556494 21.REMARK 7,,7. 7,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.853061 N -78.643724 W
12-" /,,� ,jy 4/14/22
6.Is(are)the well(s)�X Permanent or OTemporary 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: QYes or X)No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 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 I 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: 20 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dfflerent(example-3(200'and 2 t@r 100) construction to the following:
10.Static water level below top of casing: rr 1 1 (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
12.Well construction method: g
aU er above,also submit one copy of this form within 30 days of completion of well(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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&Iniection 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 to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016