GW1-2021-00283_Well Construction - GW1_20210125

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ; ,:
14.WATER ZONES
Virgil Wilson `
FROM TO DESCRIPTIOV
Well Contractor Name 3 ft. 14 ft I-:♦ ,M _ We[.'''3r..,
4473
NC Well Contractor Certification Number 15.OUTER CASING formulfi-casedwells OR LINER ifa 6cable
FROM TO DI TER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. ! in.
Company-Name 16.INNER CASING OR TUBING(geothermal tilosed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ff: 0 ft. 4 ft. 2 i"' SCh40 PVC
List all applicable,cell pernats(i.e.Counw,,State, Variance.Inlecdo,etc.)
in.
3.Well Use(check well use): 17.SCREEN
Water Supply'*y*ell: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 4 ft. 14 ft• 2 "-j 1 .010 SCh40 pvC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0.5 ft• 1 ft. Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recover 1 ft. 2 ft- Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 tt. 14 ft- #t Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if;necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
4.Date Well 12/17/20 s)Completed: Well IDt! MW-1 ft. ft.
ft. fr.
5a.Well Location: fr. ft.
Town of Cary Walnut Creek Pump Station ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1100 Buck Jones Road, Cary, NC
ft. ft.
Physical Address.City,and Zip 21.REMARKS
Wake 773654786 s"FMC
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Ce ification:
(ifwell field,one tat/long is sufficient)
35.771423 N -78.742134 W. 4
�- /-2va t
Signatur fCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary BY signing ibis lortn, I herebv certi(i,that the,re//(s)i as(trere)constructed in accordance
With I SA N'A•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 ut the it owner.
if this is a repair,Jill oar known sell construction information and erplain the naatre of the
repair sunder��21 reinorks section or on the back q/'this/tarn,. �i fl23�,.5�ite diagram or additional well details: -
�„ '•:� 1 lyou may use the back of this page to provide additional well site details of well
corStruction details. You may also attach additional pages ifnecessary.
8.Number of wells constructed: \ p g
For i n iliple injection or non-waver.snpply u•e//s ONLY with the same c2in$iriicribn,volt can '
submit one Jarnt. p tb'( MITTAK INSTUCTIONS
9.Total well depth below land surface: J (ft.) 2t `Fiir All Wells: Submit this,form within 30 days of completion of well
1•itr mu/triple it ef/s list al/depths i/di/Jerent(example-3 nlll(1'and 2@ 1001) COh$jibclion to the following:
{j1
1f�'1`!
10.Static water level below top of casing: 3 "i�� t \')'�fijL) Division of Water Resources,Information Processing Unit,
Ijlvater level it ahm a casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 8 1/'4 (in.) 24b. 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 m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days ofcompletion 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
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