GW1--02234_Well Construction - GW1_20240408

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 ft. ft. f I
'
4473A 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 p ;;in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 13 ft- ' 1n' 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 15 ft. 30 fL 2 '°' .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ' ft. ft. in.
( S/ g PP Y) PP Y( g )
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT '.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
['Irrigation 0.5 fL 11 Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 11 ft• 13 ft Bent. Chips Poured
Injection Well: ft. ft.
❑Aquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ID Salinity Barrier ft fL '
13 30 #1 Sand Tremie'
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
['Experimental Technology ['Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
['Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) 1 ft. 9 ft. Soil-brown, Red, Black, Moist, Soft/M. Stiff,
3/20/24 MW-1A 9 fL 21 ft• Soil islRed, Brown, Black, Moist, M.Stiff, Cla
4.Date Well(s)Completed: Well ID# .
ft. ft. �"' �1 S..n 4
5a.Well Location: ft. ft. '�� I
BP BP 261 ft ft. APR OF ZOC4
Facility/Owner Name Facility ID#(if applicable) ft. ft. .
1535 Hwy 70 West, Garner ft. ft ; trri--,,.
Erc..:1,OC
Physical Address,City,and Zip 21.REMARKS
Wake 8"Flush Mount Cover Installed
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: '.
(if well field,one lat/long is sufficient) 22. ertification: j
35.723028 N -78.646987 4_ ; . z - D S- D y
Signature Certified Well Contractor j; i Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A 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 ONo copy of this record has been provided to ttie well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 421 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
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@200'and 2@I00') construction to the following:
10.Static water level below top of casing: unknown (ft) Division of Water Res tirces,Information Processing Unit,
If water level is above casing,use"4-" 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: NSA construction to the following:
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(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources?Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&InjectionWells:
Also submit one copy of this fo l n within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised Au,
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