GW1--05838_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.WATER ZONES
FROM TO •
DESCRIPTION
Well Contractor Name 9.79 ft. 20 ft I I Wet •
4473 ft. ' ft.
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. 7 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 7 ft. 17 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
❑Irrigation 0 ft. 1 ft. Concrete Poured
Non-Water Supply Well:
❑OMonitoring ❑Recovery 1 ft 3 ft Bentonite Cer Poured
Injection Well: 3 ft. 5 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
5 ft. 17 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,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
7-17-23 MW-26 ft. ft. 1 ""
4.Date Well(s)Completed: Well I j- `� t�t t �"j D#
ft. ft. s is ka.' ; V �. J
5a.Well Location: ft. ft.
City of Raleigh ft. ft. SEP ') 1 7f123
Facility/Owner Name Facility ID#(if applicable) , s• vrn 5,a.'o;;'.n i;r.;:
ft. ft. Incas rf'' ' n t I
1014 N West Street, Raleigh, 27603 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Wake 1704538007 24"sonotube;4"stick-up
County Parcel Identification No.(PIN) Four 3"bollards
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) ,
35.79139 N -78.64362 Nt VLQ.._c,
Q \&s: . e't (° ' d-
Signnature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,/hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1.5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or OND copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under a21 remarks.section or on the back ofthi.sfortn. 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: 20 (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@200'and 2@100') construction to the following: '
10.Static water level below top of casing: 9'79 (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 Infection Wells ONLY:1 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 Resource ,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,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. l
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water;Relsources Revised August 2013