GW1--05828_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Virgil Wilson 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name 10.03 ft 30 ft I Wet
4473 ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased:wells)OR LINER(if ap!licable)
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. ' in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#. N/A 0 ft* 20 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 SLOT SIZE - THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 ft. 30 ft. 2 in. 010 sch40 PVC
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [Residential Water Supply(single)
❑Industrial/Commercial [Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 1 it. Concrete Poured
Non-Water Supply Well:
OMonitoring ❑Recovery 1 ft- 16 ft• Bentonite Cer Poured
Injection Well: 16 ft 18 ft• Bentonite Chil Poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
[Aquifer Storage and Recovery ❑Salinity Barrier
18 ft. 30 ft #1 Sand Poured
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,gratin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft
7-20-23 MW-20 D ft. f` - =�,-'' r.1
4.Date Well(s)Completed: Well ID# ft. ft ' �"&",t`„ - r� �
`�^ ' i
5a.Well Location:
ft ft SEPJ12023
City of Raleigh ft. - ft '
Facility/Owner Name Facility 1Db(if applicable) ft ft. lit ,na- -..a Pr,.•..-s rv.:.to tit::i
INV 317?.CA7,
1014 N West Street, Raleigh, 27603 ft ft
Physical Address,City,and Zip
21.REMARKS
Wake 1704538007 4"Stick up
County Parcel Identification No.(PIN) 4 Bollards(3°)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lat/long is sufficient)
35.78897 N -78.64384 w k. eck\ ��k�,p 2 . (3-a1 3
Sig ture of certified Well Contractor ! Date
6.Is(are)the well(s): ( Permanent or ❑Temporary By signing this form,I hereby certi. that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or JNo copy of this record has been provided Id the well owner.
1f this is a repair,fll out known well construction information and explain the nature of the
repair under.21 remarks section or on the back of this 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-water supply wells ONLY with the same construction,you can I
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a?00'and 2 a l00') construction to the following:
10.Static water level below top of casing 10.03 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"•-" 1617 Mail Service Center,Raleigh,NC 27699-1617
8"to 23 ft and a°to 30 ft 24b. For Injection Wells ONLY: In addition to sendin the form to the address in
11.Borehole diameter: (in.) g
HSA and Air Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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'einter,Raleigh,NC 27699-1636
24c.For Water Supply&Injection!Wells:
13a.Yield(gpm) Method of test:
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
III