GW1-2022-08685_Well Construction - GW1_20220419

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Virgil Wilson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ��, B ft. ft. I
4473 5 aFrF
ft. rL
EO
NC Well Contractor Certification Number (► 2(�22 15.OUTER CASING for mulri-eased wells OR LINER if a licable
APR 1 v FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. urn rt. fr. I in.
Compam Name ,OpjteI1 � � 16.INNER CASING OR TUBING eothermal dosed-loo
4t FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 3 R• 020 '"' SCh40 PVC
List all applicable well permits(i.e.Coun(r.Slate,I,arianc•e,Injection,ete.J
ft. fr. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 tr. 18 rt. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fr. i"•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 1 fr. 2 t" Bentonite Chil Tremie
Non-Water Supply Well:
ft. ft.
IZ Monitoring ❑Recovery
Injection Well: R. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 ft' 18 ft. #2 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additlon$l sheets if eecessa "
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,girain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 4-7-22 Well ID# MW-24
ft. ft.
5a.Well Location:
a. ft.
Raleigh Durham International
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1016 Rental Car Road, Morrisville 27560
Physical Address,City,and Zip i.
21.REMARKS
Wake
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one[at/long is sufficient)
35.866924 N -78.799491 W
Signature ot'C t ified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this trnt, I hereby ceriifv that the ire//(s)was(were)constructed in accordance
with I5A NC'A'02C.0100 or 15A NC'ACJ 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: 01`es or ElNo copy ofthts record has been provided to the net/owner.
1f this is a repair,fill out known well construction tnlnrmation and explain the nature of the
repair Corder=21 renmrkv section or on the back g11his Jornt. 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.
Nor nu liple injection or non-u-ater.vupply wells ONLY with the same construction,you can
submit oneJorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 18 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells fist all depths t('diflereni(example-3@200'and 2@100') construction to the following:
i
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
!/'water/erel is abare casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (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
t
m 13a.Yield
(gP ) Method of test: 24c.For Water Supplv&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 county where
constructed. `
Form GW-I North Carolina Department of'Environment and Natural Resources-Division of Water Resources Revised August 2013