WI0501115_Well Construction Record(s) (GW-1)_20240402

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells n r
1.Well Contractor Information: RECElvED
Joshua N. Robertson 14.FRROWM TO ATER ZONES DESCRIPTION
Well Contractor Name
APR 0 '' - ft ft 20GPM@200'
2461-A ft ft.
NC Well Contractor Certification Number NC DEQ/DWR 15.OUTER CASING for multi-cased we0s OR LINER if a livable
Central office FROM TO DIAMETER T uao ESS MATERIAL
Triad Drillers, Inc. 0 ft. I in,
Company Name 16.INNER CASING OR TUBING( votbermal closed-loop)
W 1050115 FROM TO DIA METER THICKNESS MATERIAL
2.Well Construction Permit#: ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft❑Agricultural ❑Municipal/Public in.
❑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
❑Irri ation 0 ft ft Bentonite
Non-Water Supply Well:
ft It.
❑Monitoring ❑Recovery
Injection Well: ft &
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft ft
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20:DRI LUNG LOG(attach additional sheets if necessa •►
EDGeothermal(Closed Loop) ❑Tracer FRO+t 7u DENOUPTION(color,hardnem,soiVnmkt. e. she,etc.(
❑Geothermal(Heating/Coolmg Return) ❑Other(explain under#21 Remarks) 0 ft 50 ft Sand
12/18/23 50 f 300 ft Granite
4.Date Well(s)Completed: Well ID# % ft
5a.Well Location: ft ft
Bowman Mechanical RDU ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
4924 Foxridge Drive, Raleigh e. ft
Physical Address,City,and Zip 21.REMARKS
Wake 1718077710
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer '[cation:
(ifwell field,one lat/long is sufficient)
N w -- AAat 12/20/2023
Signature Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby certify 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
7.Is this a repair to an existing well: ❑Yes or ❑No 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
S.Number of wells constructed: 6 _ 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
9.Total well depth below land surface: 300 _(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii erew(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 1/8 (in) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.anger,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) 20 Method of test: Air 24c.For Water SuPplc&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount 16 oz. 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

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Joshua N. Robertson FRO ATER ZONES TO DESCRnP'nON
Well Contractor Name ft ft .25GPM@ below 200'
2461-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING t for malts-cased wells OR LINER(if applicabiel
FROM I TO DIAMETER I THICKNESS MATERIAL
Triad Drillers, Inc. 0 ft ft in.
Company Name 16.INNER CASING OR TUBING eotherm_al closed-loop)
W10600246 FROM TO DIAMETER THICKINESS MATRxrAi.
2.Well Construction Permit#: ft ft ;a
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAI.
ft ft in.
❑Agricultural ❑Municipal/Public
ft ft
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply(single) in
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irrieation 0 ft 300 D' Thermal Pump
Non-Water Supply Well:
ft it Grout
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING-LOG attach additional sheet if necessan!
fflGeothermal(Closed Loop) ❑Tracer FROM rO DESCRIPTION icelor,bardn—soilt ock a .ur,eh.1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 5 ft Clay
4.Date Well 03/25/24 s)Completed: Well ID# 5 fr. 93 ft' Sand
93 ft 300 ft Granite
5a.Well Location: ft ft
Bowman Mechanical RDU, LLC
ft ft
Facility/Owner Name Facility ID#(if applicable)
ft ft
473 Fred Burns Rd, Holly Springs ft ft
Physical Address,City,and Zip 21.REMARKS
Harnett 0600246 _
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer'Ication:
(ifwell field,one lat/long is sufficient)
_N w 03128/2024
Signature Certified Well Cofactor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby certify 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
7.Is this a repair to an existing well: ❑Yes or 0No copy ofihis 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
S.Number of wells constructed: 2 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same cons&wfion,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 300 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferem(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 70 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method. Rotary _ 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 276994636
13s.Yield(gpm) '25 Method of test: Air 24c.For Water Suppy &Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: 16 oz. 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