GW1--05435_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD ForllecrnalI .af1NI N'
Tim form can he oc d for sinrk or nadaipk,.ells
I.Well Contractor information:
la.WATER ZONLS
Rich Lend re Thom ' TO 1 mesa•klP1 ION
Neil CmtracIrw Name ft, ft'
2593A ft. ft.
NC Well ContractorCenif,wt,on Number
IS.OUTER CASING[W►orMitared webl OR LITTER id ap Ikabk)
room TO to4NtTTIt tHK'UNrNt ill H'1TtVIAL
SAEDACCO n. rt. i..
Coltman)Name 14.INNRR CASING OR TL'RING)ye.Aerral clatudaoaip)
(ROM TO DUMFTFR THECA NIS''S M.y1E RIAU
2.Well Cantttrtyctime Permit K: 0 ft. 5 ft. 2 En- SCH-40 PVC
Liu 41 apphrnhk welt penwit.fir.Carlrw.Slam,Variant,. Irrectiort en.r -
R. ft. in.
3.Weil l'ae(cheek well Week 17.SCREEN -
Water Supply Will: Isom TO DtiMITRR MOT MIS TRITiorSx 1 m4rFalal. ,
LIAgricultutal OMnnicipalPtdtltc 5 ft. 10 R 2 iw .010 SCH-40 PVC
mlal iHealin ,Cooling Supply) ft. R (a
OGeothe g OResidetaial Wafer Supply(single)
Olndustrial/Commercial OResidentwl Water Supply(shafed) TO - MATERIAL EMPLACEMENT MF711O0&AMOUNT
Ohngatwn 0 ft. 4 ft. BENTONITE POURED
Non-Water Supply Well:
R. R.
El Monitoring ❑Rccosrn• ,
Injection Well: n. ' n.
[I Recharge ❑Groundwater Renicda.ui., I..,...'No,(.100,Ll r c h!if ap(iIir,blct
O Aquifer Storage and RRoxcn OSalinin Barrier "ia,,, iI, ,I t I t RI%I, IMPLACI71IVNTMRTR09
g4 ft. 10 ft. SAND #2
❑Aquifer Test ❑Siomn,:tier Drainage R. R.
❑E'tpcnmental Tcchnologs ❑Subsidetkc Comm'
211.DRILLING LOG(attach additional sheets if uecenanJ
r❑Geothemul(Closed Loop t ❑Tracer ►Rom to uxRIPTION(tutor.ra.aac..,.ntawck opt.arra,s%de,I
COGeothennal(llea►ing:Cu(litlg Return)
❑Ocher(explain under# I Renits) 0 ft. 10 R. RIVER SAND
ft. ft.
4.Date WeN(a!Completed: 8-22-2024 Well IDaaTW-1
R. fL
5a.Well Loeatino: rt. ft.
OLD RALEIGH LANDFILL 86 ft. ft.
Facility•'Oa nor Nam Faciiy IDM(if applicable)
1850 Fayetteville St., RALEIGH, NC, 27603 p, R. `�1/40 i ,/) !,.
Physical Addicss.City.and Zip a piximins ' ' - - -
WAItE
(Amity Parcel ldc.ad,catiun No 'PIN' lr. ..:n.:rr�,_-. _ ,...ti. .
56.(Latitude and I.ongitide in dcgretslminutrsiacennds or decimal degrees: 22 Celt abet:
Orwell rend.one taWlons is sufficient)
of� �
N W' _.e,,.Nr.•..,. 8/22/2024
Signature of Ceni Well Connector [htte
6.Is Caret the wells): Permanent or I1Temporan 8,signing Mu ftmn.I larrrhi certify that the wel(al war(*err)naatrtracted an accordance-
with 15A NCAC 02C,01(57 or I IA NCAC 02C.0200 Wei Corntrewhon Smalards and that a
7.Is this a repair to an esistieg nen: 2JVest or RN* corn of chi,record ha.!sera,p,".akd Of the toll awv,eT.
If this Ito repair,rill oar(n,,art nett,nnolr,y Ida,Information sal rrltiolta the ti ararr of rhr
repair alder 021 reanan6..shun arm chr bark of this form. 23.Site diagram or additional well details:
You neat use the back of this page to pro%ide additional well site details UT well
8.Number of welb coamtracted: 1 construction details. You may also attach additional pages of neeessan.
Far.nalitple u,rcrp:or,a,,,,,i-,..are,Land,„ill,ONLY nay,MC*ante ruuvrieN,a, Wit tam
sabmirone f..rw. SIJBMMITTAL INSTIICTIONS
9.Total well depth Itch,.. Land surface: 10 (B,) 24a. For An Wells: Subnot this fur, within ill days of completion of well
For malttpk,. ...ample• am'itr'Ind,'w Iioc t constmctton to the fallowing.
IL Stalk wmr lc%el helm% nip.rf c,0•11,2: 5 (n,) Dirishan of Water Resources,lefonnatinu Processing l nit.
If MOO'ksrt at,bore,,1. , 1617 Mail Service Center.Raleigh.NC 27699-1617
II.Borehole diameter:8.25" tin., 24b.For Inkctioo Wells ONLY: In addition to sending the form to the address in
24a abose. also submit a copy of this form within 41 days of completion of well
12.Well d,eSInk-tinn method:NSA tOttsttltc't nit to the following.
(lc..taxxr.roan.cable.dircct push.etc.)
Dhilkn of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Rakich,N( 2'699-1636
13a.Yield(jaunt_ Method of hat _ 21c.Ear«ales`upph .1:.htjntion Wells:
Also submit one cops of this form w idiot tin das s of completion of
I3b.Disinfection trPc---
Amount- well construction to the county' hcahh department of the county where
constructed
Form GW-I Monti Catalina ticpcaniecni of Em uotuunt and Natural Resources-Melon of Wales RPo[/Cm Raved A4120 2013