GW1--05832_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:
VlrVirgil Wilson 14.WATER ZONES
9 FROM TO DESCRIPTION
Well Contractor Name 8.77 ft' 16 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 1 THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. i
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A 0 ft 6 ft 2 ; in' 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 6 fr. 16 ft 2 i°' .010 sch40 pvc
ft. f. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ID Residential Water Supply(shared) 18.GROUT
FROM _ TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 2 ft. 4 ft Bentonite Chii Poured
Non-Water Supply Well:
❑O Monitoring ❑Recovery 0 ft 2 ft Concrete Poured
Injection Well: ft. ft
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM _ TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier
4 ft 16 ft. #1 Sand Poured
DAquifer 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,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft ;
7-12-23 MW-21 ft. ft. , C t
4.Date Well(s)Completed: Well ID# _ 7.... '"�tf t ' 7- rn.
ft. ft c r:LP I. �II-�...-
5a.Well Location: ft. ft.
City of Raleigh ft ft jL' W 1 202
3
Facility/Owner Name Facility 1D#(if applicable) ft. ft lfltCiriX,2 .Sl Pr ^. Rio'.'. l%f
1014 N West Street, Raleigh, 27603 ft ft. I,ti�tw
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.yertifrcation:
(if well field,one lat/long is sufficient) ,
35.789551 N -78.643272 w \ QC& ( c � . (0 ..;23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,1 hereby certj that the we//(s)was(were)constructed in accordance
with I 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 EJNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain he nature of the
repair under v21 remarks section or on the hack 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
submit one form. SUBMITTAL INSTUCTIONS ;
9.Total well depth below land surface: 16 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list a//depths if different(example-3@200'O00'and 2@100') construction to the following: '
10.Static water level below top of casing 8.77 (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: 8 (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
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ceinter,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
constntcted. I
Fonn GW-I North Carolina Department of Environment and Natural Resources-Division of Water R Isources Revised August 2013