GW1-2022-08680_Well Construction - GW1_20220419

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Virgil Wilson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft
4473 ° ' D ft. ft
t
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells`OR LTNER if a licable
FROM TO DIAMETER' THICKNESS MATERIAL
Parrott-Wolff, Inc. APR 1'9 2022 fi. ft. in.
Company Name ) � "71 Prt?C.LiG=g urLo 16.INNER CASING OR TUBING other a]closed-loop)
prt."ls.t' FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: D%VQ/G0G 0 ft. 3 rt• .020 in. SCh40 PVC
List all applicable well permits(i.e.County.Slate, Variance,Injection,etc'.)
ft. I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 1t. 18 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 1 tt. 2 rr. Bentonite Chil Tremie
Non-Water Supply Well: ft. fr.
EMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable'
.. FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
2 fr. 18 fr. #2 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
fr. fr. I
❑Experimental Technology ❑Subsidence Control
20.,DRILLINGLOG,attach:additionalfsheetsifnicessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well 4-6-22 s)Completed: Well[D# MW-22
ft. ft.
5a.Well Location:
Raleigh Durham International
Facility/Owner Name Facility ID#(if applicable)
1016 Rental Car Road, Morrisville 27560 ft f.
Physical Address,City,and Zip
21.REMARKS
Wake
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22• -ertif n:rc
(if well field,one lat/long is sufficient) F f '
35.866814 N -78.799422 W ^\V// '7 f
Signature of C ified Wel Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this Jorni,I hereby certify that the we/I(s)was(were)constructed in accordance
with 1 5A NCAC 02C.0100 or 1 5A NCAG 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy gf1his record has been provided to the well owner
q this is a repair,fill out known well construction information and explain the nature at the
repair under-21 remarks section or on the back q/'dus farm. 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 muhiple injection or non-water supply we/h ONLY with the same construction,you can
submit oneJorm. SUBMITTAL INSTUCT(ONS
9.Total well depth below land surface: 18 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhiple wells list all depths 4*diJferen1(example-3@200'and 2 a l00') construction t0 the following:
10.Static water level below tap of casing: (ft.) Division of Water Resources,Information Processing Unit,
tl water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Iniection Wells ONLY: lin addition to sending the form to the address in
24aabove, 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
(gP ) 24c.For Water Supply&Injection'Wells:
m 13a.Yield Method of test:
Also submit one copy of this form within 30 clays ofcompletionof
136.Disinfection type: Amount: well construction to the counh health department of the county where
constructed.
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013