GW1-2021-01171_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
James Robertson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 15 ft. 23 ft. Wet
4482 ff. ft.
NC Well Contractor Certification Number 15.OUTER CASING for muiH-cased wells)OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 e. 13 ft. 4 in. sch40 pvc
List all applicable well pernnav(i.e.Couay.Slate, Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 13 ft. 23 ft' 4 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT I_
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 8 l" Portland Cem Tremie
Non-Water Supply Well:
MMonitoring ❑Recover- 8 ft 11 ft• Bentonite Chii Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 11 ft. 23 ft' #2;Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets ifnecessa '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 5 ft. Hand Clear
4.Date Well(s)Completed: Well ID#
12/22/20 RW-1 5 ft- 15 ft. Brown, dense,clay,fine sand and silt
ft. ft.
5a.Well Location:
ft. ft.
Wake County Board of Education Fuquay-Varina Elementary
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
6600 Johnson Pond Road, Fuquay-Varina NC ft. ft.
Physical Address,City,and Zip
%21.REMARKS
Wake 0677148461
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certitic
(ifwell field,one[at/long is sufficient)
35.602414 N -78.757689 w
nature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary by.signing this firm, l hereby certify that the❑•ell(s)eras(were)constructed in accordance
wish 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 E]No copy afthis record has been provided to the well owner.
lfthis is a repair,fill oaf knomn well construction information and explain the nacre(if the
repair under=21 remarks section or on the back q/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-nvater.supph,wells ONLY wah the same construction,volt can
submit one.form. .F v,` I B)IITTAL INSTUCTIONS
9.Total well depth below land surface: 23 .), �" (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
'or nmhiple wells list all depths ifdiffereni(example-3 a 200'and 2@100') jaisWction to the following:
10.Static water level below tap of casing: 1 5 �� (ft) s. Division of Water Resources,Information Processing Unit,
ri �.,tl�t 1617 Mail Service Center,Raleigh,NC 27699-1617
/flrater level is above casing.use'•- ' -,.nf{� .,�,�� d
11.Borehole diameter: 101/4 (in, hil�nf' '� r"�'t,�db. For Infection 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: HSA 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:
i
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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
i