GW1-2021-02169_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
L Well Contractor Information:
Virgil Wilson oiEso 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name \ 5 rr. 13 ft. Wet
4473 5v ,� i TO fL ft.
NC Well Contractor Certification Number j�.�L g51�9 U7i11� 15.OUTER CASING for multi eased wells OR LINER if a ticable
9 FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. �prc� ft• ft.
in.
Company Name �117% ° D i�" 16.INNER CASING OR 7•[iBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fr. 3 tt. 4 in. sch40 PVC
List all applicable well perntits(i.e.('aunty.State,Variance,lnjec•lion,etc•.) in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 fL 13 fr' 4 in' .010 Sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft, 1.5 ft- Portland Cem Tremie
Non-Water Supply Well:
1.5 ft. 2 ft. Bentonite Chi Tremie
OMonitoring ❑Recover
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
3 ft• 13 ft. #1 Sand Tremie
[]Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach addiNorial sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,girain sin.etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
6-5-21 RW-03 f. ft.
4.Date Well(s)Completed: Well ID# ft ft.
5a.Well Location: ft. ft.
USCG Cape Hatteras ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
59248 Coast Guard Road, Hattteras 27943 ft. ft,
Physical Address,City,and Zip -
21.REMARKS
Dare
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22, ertification:
(if well field,one lat/long is sufficient)
35.208453 N -75.704329 W. J
Signature o)ACO2C.0100
Certified Well Contra' r Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary gt;signingits Jorn, /herehy cerijy that the well(s)was'(were)constructed in accordance
,,all hA N or 15A NCAC 02C.0200 Well Construction Standards mud that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
It this is a repair,fill ow known well construction information and explain the nature of the
repair under z21 remarks section or on the back q(this larni. 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.
Fbr multiple injection or non-waier supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 13 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/•'or multiple wells list all depths it chJJerent(example-3@200'and 2 n 100') construction to the following:
10.Static water level below top of casing: 5 Division of Water Resources,Information Processing Unit,
/l water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Injection Wells ONLY:! In addition to sending the form to the address in
8 1/4 HSA 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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
m 13a.Yield
(gp ) Method of test: 24c.For Water Supply&Injection Wells:Also submit one copy of this for,m 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