GW1-2022-07950_Well Construction - GW1_20220823

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells f
L Well Contractor Information:
Virgil WIISOn 14.WATER ZONES i
g FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4473 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulct-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING eo'thermal closed-loop)
FROM I TO DIAMETER[ I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 30 ft. 2 i" 1 Sch40 I PVC
l.&I all applicable well permits(i.e.Coun(v,,~Tale,Variance,hyeclton,etc.)
ft. ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30 ft' 40 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. it. in.
❑Industrial/Commercial El Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT NIFIAOD&AMOUNT
❑►rri ation 0 rt. 26 ft- Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovenv 26 rt 28 rt Bentonite Chii Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PAC K if a licable
FROM TO MATERIAL EMPLACEMENTMHTHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
28 rt• 40 rr• #1!Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION culur,hardness,soil/ruck lylic,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well(s)Completed: 6-8-22 Well ID# MW-9SKR ft.
5a.Well Location: ft. rt. 7
Midtown East Regency-ITB,LLC
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
In'C;' ,
1200 Wake Town Drive, Raleigh it.
Physical Address,City,and Zip
21.REMARKS
Wake 1715244007 8"FMC
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22. ertifieatio
35.813578 N -78.622609 W
Signature of a ifhe ell Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing ids/orm, l hereby cerrt[i,that the wells)wus(mere)construcled in accorduhce
with 15A NC'AC 02C.0100 or 15A NCA(i'02C.0200 Well Cuns'Iructiun J)wtdurdv and that a
7.Is this a repair to an existing well: ❑Yes or ElNo cony gl'thi.s record has been prorided to the well owner.
lfthis is a repair,till ova known well consiruelion information and erplain the nature o/lhe
repair under all renutrkr section or on the hack gftls,jbrnn. 23.Site diagram or additional well details:
You may use the back of this page jto.provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
hor multiple injection or non-water.supply u'el/r ONL F with the same construction.You can
.submit one/ihrnt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 40 24a. For All Wells: Submit this'torm within 30 days of completion of well
hor multiple wells list all depths i(dt/Jereni(example-3@200'and 2«/Illy) construction to the following:
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10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
?/hater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
8hh i
11.Borehole diameter: (in.) 24b. For Infection Wells ONLY: 1 lifaddition 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:
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. I I
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013