GW1--00326_Well Construction - GW1_20240112

IF Print Form
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Daniel Summers 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3 ff. 18 ft. I '
2579-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Carolina Soil Investigations, LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. 1 in.
Company Name 16.INNER_ CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WMO5O1599 FROM TO DIAMETER - THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 3 ft. 2 , in, sch 40 pvc
3.Well Use(check well use): ft. ft. , in.
Water Supply Well: 17.SCREEN
FROM _ TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Q Agricultural 0Municipal/Public 3 rt. 18 ft. 2 in'_ 010 sch 40 pvc
Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
0 Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
0 Irrigation Q Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2 ft. portland mix&pour
LEI Monitoring 0 Recovery
2 ft. 2.5 ff. bentonite tremie
Election Well: ft. ft.
Aquifer Recharge El Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
['Aquifer Test D StormwaterDrainage 2.5 ft. 18 ft. 10/30'silica sand tremie
D Experimental Technology 0 Subsidence Control ft. ft.D. Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
'1 ( g/ g 0 Other(explain under#21 Remarks) 0 ft. 18 ff. brown!silt loam/brown silty clay/saprolite
4.Date Well(s)Completed: 12-07-23 Well ID# MW-5 MW-4 MW-3 ft. ft. I
5a.Well Location: ft. ft. I 'r:;o i�(Li, i y t.; )
Circle K 2723119 UST Incident#48180 ft. ft. I��+' ?
Facility/Owner Name Facility ID#(if applicable) r,'� ��-�
ft. ft. •
1137 North Brightleaf Blvd Smithfield, NC \ ft. ft. : In.v;7n::i.T`D?f.: � t%'
Physical Address,City,and Zip ft. ft. C"`C
Johnston (PIN#260414-34-3494) 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:
35.50512 N -78.31574
W
1)t"--S (Cs--2.-�--- 12-07-23
6.Is(are)the well(s):tl Permanent or El Temporary
Signature of Certified Well Contractor , Date
7.Is this a repair to an existing well: D Yes or No By signing this form,I hereby cert�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
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: 3
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3@18' (ft.)
For multiple wells list all depths if different(example-3@200'and 2@I00') 24a. For All Wells: Submit this'form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 4 5 (ft.) I
Il water level is above casing,use"+" Division of Water Resources,Information Processing Unit,
8" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For Injection Wells:In addition to sending the form to the address in 24a
12.Well construction method: auger 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: I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,ep 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 to the county health department of the county
where constructed. '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018