GW1-2022-08689_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 WIISOn 14.WATER ZONES
FROM TO DESCRIPTION
fr.
Well Contractor Name ft. �
4473 QQ ((�� ft. ft.
APR IS 2022 15.OUTER CASING for multi-cased wells OR LINER if a ticable
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. lnforvrrla5cin Proor, Ig Un ft. fr. in.
n+a.Jr1 fP14Vi
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fr. 5 ft. 020 'n' SCh40 PVC
List all applicable hell permits(i.e.Coanly.State, Variance.lr feciion,etc.)
ft. ft, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft' 15 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
❑Itri ation 1 ft. 3 a• Bentonite Chil Tremie
Non-Water Supply Well:
ft. ft. Tremie
IDMonitoring ❑Recovery
Injection Well: ft. fr.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACKifAplicable
.. FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
3 ft• 15 ft. #2''Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLfNG'LOG ttkth additional sheets if necessa _
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 4-4-22 MW-16 ft. ft.
$)Completed: Well ID# ft. ft.
5a.Well Location:
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•Certifica 'on:
(ifwell field,one[at/long is sufficient)
35.866600 N -78.799682 W �1
Signature I
Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this Jorm,1 herebv cerlifi,that the wells)was(were)constructed in accordance
wah 1 SA NCAC 02C.0100 or 15A NCAC`.02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ZINo copy gfihis record has been provided to the use//owner.
If lhis is a repair,fill oul known well construction inforntaiton and explain the nature of the
repair under:,'21 remarks.section or on the back q/'this Jhrm. 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 ofwells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-traler supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 15 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
Fbr muhiple wells list all deplhs tl t#lferem(example-3@200'anc12 tt 100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Injection 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 m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
136.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 1-013