GW1--00508_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Matt Steele 14.WATER ZONES
FROM TO DESCRIPTION •
Well Contractor Name ft. ft.
4548-A ft. ' ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft. ft. 1 in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)"
WM050159I FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft. 2 I in Sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in
I
3.Well Use(check well use):
17.SCREEN . � 3 ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 20 ft. 2 1D 0.010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 1 ft. grout i pour
Non-Water Supply Well: 1 ft. 3 fi bentonite pour
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) >"
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier 3 ft. 20 R' #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage .
ft. ft.
❑Experimental Technology ❑Subsidence Control i
20 DRILLING LOG(attach additional sheets if necessary)''>>_ tx s
0 Geothermal(Closed Loop) El Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft• 0.6 ft. Concrete
11/14/23 MW-12 0.6 ft. 11 ft. Silty clay
4.Date Well(s)Completed: Well ID# 11 fi• 15 ft. 1 Clay
5a.Well Location: ft. 20
Apex Food Mart 00-0-0000006819 15 ft. •20 ft. r, clay
Facility/Owner Name Facility ID#(if applicable) ft. K�,";6--
•�
321 South Salem Street, Apex, 27502 ft. . fft t.. `JAv 1 s 2G24
Physical Address,City,and Zip 21.REMARKS _<-.
Wake 0741394692 tn „ r.:i P.. ,. 72 g urr'i
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i
(if well field,one lat/long is sufficient) ,,'
35.727427 . N 78.853966 W 11/14/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,I hereby cerhJy that the well(s)was(were)constructed in accordance
with 1SA 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 ONo copy of this record has been provided to the well owner.
If this is a repair,fill 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: 1 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 j
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 different(example-3 a@200'and 2@100' construction to the following:
t
10.Static water level below top of casing: 1 3.01 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service 1 enter,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
Solid Stem Auger
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:
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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013