GW1-2022-07951_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
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1.Well Contractor Information:
Vlr II Wilson 14.WATER ZONES
g FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4473
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER I THICKNESS MATERIAL
Parratt-Wolff, Inc. 0 ft. 6s II• 6 i sch40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rt. 72 ft. 2 i" SCh40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 72 ft. 82 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 rr. 70 ft- Portland Cem Tremie
Non-Water Supply Well:
M Monitoring ❑Recovery
70 R• 71 It. Bentonite Chii Tremie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
71 rr. 82 rr. #1 jsand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additions 1 sheets if necessary)
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,suilhockt ne,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
6-8-22 MW-9DKR
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Midtown East Regency-ITB, LLC
_ '-"•.�
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Facility/Owner Name Facility ID#(ifapplicable) ft. ft. ��s..^•`t1i'` i r
1200 Wake Town Drive, Raleigh ft. ft.
Physical Address,City,and Zip
21.REMARKS
Wake 1715244007
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 C ificatio
(ifwell field,one lat/long is sufficient)
35.819574 N -78.622635 W • Z�
Signature ofC ivied Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary Hv signing this jormt,1 herehv ceri/&that the well(s)wus(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC;01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy q/this record has been provided to the we//owner.
ll'this is a repair,Jill out known well consiruc•tion inlormalion and explain the nature gl'lhe
repair under-21 remarks.section or oil the back a/th/s.form. 23.Site diagram or additional well'details:
You may use the back of this page to provide additional well site details of well
S.Number of wells constructed: 1 construction details. You mat also attach additional pages if necessary.
hbr multiple injection or non-w tter supply wells ONLY with the Name construction,you can
submit oneJorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 82 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr multiple wells list all deplhs il'di/jereni(example-3@a 200'and 2 a 100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
1/water level is above casing,use " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 On/6" (in) 24b. For Iniection 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.) I'
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 of completion of
13b.Disinfection type: Amount: well construction to the county health department of the count'where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013