GW1-2022-03339_Well Construction - GW1_20220314

i
A
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Lewis LeFever 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 20 ft. 26 ft. I wet
2480
NC Well Contractor Certification Number 15.OUTER CASING-for multi-cased wells OR LINER if a licable
FROM TO DIAMETER ! THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft.
I iti.
Company Name 16.INNER CASING OR TUBING eothermal closed-l000ll
FROM TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 2 ft' 16 ft. 2 i" SCh40 I PVC
List all applicahle well perntil.s(i.e.Cot nY.Slate,Variance,injection,etc.)
ft. fG in.
3.Well Ilse(check well use): 17.SCREEN
Wafer Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Puhlic 16 f?. 26 ft. 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. I ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT is
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft 11 ft- Portland Cem Tremie
Non-Water Supply Well:
11 f` 14 ft Bentonite Chi Tremie
0 Mon itoring ❑Recovery
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licalile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
f` f`
❑Aquifer Test ❑Stormwater Drainage 14 26 #1 Sand Tremiert. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG"attach additional"sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,suil/rucktype,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: 2-21-22 Well 1D# MW-1-R-Z
5a.Well Location:
William Newton fr. MAR 1
Facility/Owner Name Facility IDH(ifapplicable) ft. ft. `
104 Bayleaf Drive, Raleigh 27615 ft. ft.
Physical Address,City,and Zip
21.REMARKS
Wake 1 FML with sono tube
County Parcel Identification No.(PIN)
51h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(ifwell field,one lat/long is sufficient)
35.917572 N -78.644738 -
S tature of Certified W II .untractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing dtis Jorni, herehv c•erli(y that'rite irel/(,) Was(w ere)constructed in uc'c'ordonce
with 15A NCAf•02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that u
7.Is this a repair to an existing well: ❑Yes or E]No rapt,o/'this record has been provided t,the Well owner.
ll'li is is a repair,Jill oul known Well construction inlornnalion and explain the nature o0he
repair under=21 remarks section or on the back o/this Jorm. 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.
Hor nndrip/e injection or non-water supply Wells ONLY troll the same construction,you can
submit one.lornn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 26 (ft.) 24a• For All Wells: Submit this form within 30 days of completion of well
hor iuhiple ire//s list all depths it tl ilmni(example-3@200'and 2(-t�r,100) construction to the following:
10.Static water level below top of casing: 20 Division of Water Resources,Information Processing Unit,
{/hater level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection 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: 4 1/4 HSA construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Llnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ceniter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form 4within 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'Environntent and Natural Resources-Division of Water Resources Revised August 2013