GW1--06638_Well Construction - GW1_20241108

WELL CONSTRUCTION RECORD For Internal Use ONLY: •
This form can be used for single or multiple wells
1.Well Contractor Information: I • '
Joshua N. Robertson FRO ATERZOONES 'DESCRIPTION
Well Contractor Name ft ft I 5GPM@190'
• 2461-A • ft. ft I , 15GPM@400'
NC Well Contractor Certification Number .15:OUTER`CASING(for multi-cased'wells).ORLINER(if ap'heable)- --•
FROM TO DIAMETER I THICKNESS MATERIAL
• Triad Drillers, Inc. o ft. ft. i
Company Name •16.INNER CASING OR TUBING closed-loop) • '
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. I in.
3.Well Use(check well use): :'17.SCREEN _
Water Supply Well: FROM TO DIAMETER SLOT SIZE , THICKNESS ; MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) rt. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT 'c.y
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 450 ft Thermal Pump
Non-Water Supply Well:
❑Monitoring '. ❑Recovery ft
Injection Well:
ft ft
-❑Aquifer Recharge OGroundwater 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 sheets if necessary)`. ..
ElGeothennal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.) '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt. 5 ft. 1 Clay
4.Date Well(s)Completed: 10/31/2024 Well mil 5 ft. 35 ft. Sand
35 ft. 450 ft Granite
' 5a.Well Location: ft. ft
Bowman Mechanical • -'- j _�
ft ft. 1.-7 .4.Q, u Fi
Facility/Owner Name Facility ID#(if applicable) ft. ft.
N 0
1632 Pond Spring Drive Wendell' ft ft. I �024
Physical Address,City,and Zip l I , .:,f r
'21�.REMARKS. .. -'-r! . �� :
Wake 1763987788 "°
County Parcel Identification No.(PIN) '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce ''cation: i
(if well field,one lat/long is sufficient)
a ; °
N W 11/6/2024
Signature Certified Well Contractor I Date
6.Is(are)the well(s): ©Permanent or OTemporary
By signing this form,I hereby cert fy 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 ElNo,_ _ 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
9.Total well depth below land surface: 450 (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@200'and 2@l00') construction to the following:
10.Static water level below top of casing: 30 (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: 6 1/8/$ (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
12.Well construction method: Rotary construction to the following: i
(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) 20 Method of test Air 24c.For Water Supply&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 i ealth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Watei Resources Revised August 2013