GW1-2022-08686_Well Construction - GW1_20220419

WELL CONSTRUCTION RECORD For Internal Use ONLY: i
This form can be used for single or multiple wells 4
1.Well Contractor Information:
Virgil Wilson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4473 ��,7- NID rt. ft.
NC Well Contractor Certification Number
`z F 15.OUTER CASING for multi cased wells OR LINER if 8 fii able
FROM ft TO ft DIAMETER'n THICKNESS MATERIAL
Parratt-Wolff, Inc. APR i 2022
Company Name UM 16.INNER CASING OR TUBING _-tothermal closed-loop)
iniorw't .�'l Pro +9 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 01fNQ1E'.'i0G 0 ft' 3 ft. •020 in' SCh40 PVC
List all applicable ire//permits(i.e.County,Slate,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 ft- 18 f- 2 in.' .010 sch40 PVC
❑ ft. ft. in.
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 1 ft. 2 e. Bentonite Chil Tremie
Non-Water Supply Well:
ft. ft.
0 Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licible
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. fr. �Sand Tremie
2 18 #21,
❑Aquifer Test ❑S[ormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
21L DRILLING LOG attach fiddi6onit sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rack typC,gMiD size,etc.
❑Geothermal(Heating/Cooling Rearm) ❑Other(explain under#21 Remarks) ft. ft.
4-5-22 MW-20 ft. ft.
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Raleigh Durham International ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
1016 Rental Car Road, Morrisville 27560 ft. ft.
Physical Address,City,and Zip '-21.REMARKS 1:,
Wake
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
35.866689 N -78.799564 W ( S
Signature I;,
et h Well ontractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By.signingform,I hereby certify that the uvell(s)u-as(here)constructed in accordance
with 15A 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy at'dus record has been provided to the well owner.
U'llus is a repair,fill out known uvell construction igl6munion and explain the nature of the
repair under=21 remarks section or on the back o/7his form. 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 multiple injection or non-hraler supply hrelly ONLY milh the same construction,von can _
submil one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 18 (ft.) 24a. For All Wells: Submit this.form within 30 days of completion of well
For multiple wells list all depths i/'dt/ferenl(example-3@200'and 2 a 100') construction t0 the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ry'naler level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
1.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.) 1
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&Infection 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.
,P
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013