GW1-2022-08672_Well Construction - GW1_20220419

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Virgil Wilson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ! ft. ft.
4473 "5
NC Well Contractor Certification Number APR 1 �7 15.OUTER CASING for multi-cased wells OR LINER if a 6cable
y FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. pro2w.-Mg U0 ft. ft. I
i in.
Company Name �n �t�{(�1� 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM I TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft. 3 ft. .020 in. SCh40 I PVC
List all applicable irell permits(i.e.('aunty,State, Variance,h jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural - ❑Municipal/Public 3 e. 18 ft• 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROAT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 1 ft. 2 ft. Bentonite Chil Tremie
Non-Water Supply Well: ft. ft.
0 Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a Iicible
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 rt. 18 ft #2 Sand Tremie
❑Aquifer Test ❑StornnWater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionid sheets if nicessa _
❑Geothermal{Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin sin,etc. r
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 4-6-22 s)Completed: Well ID# MW-21
ft. ft.
5a.Well Location:
ft. ft.
Raleigh Durham International ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1016 Rental Car Road, Morrisville 27560 ft. ft.
Physical Address.City.and Zip 21.REMARKS
Wake
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22• ertiftca ' n:
(ifwell field,one[at/long is sufficient)
35.867443 N, -78.798965 W =
Signat re of rtified Well Contractor - Date
6.Is(are)the well(s): OPermanent or ❑Temporary gy signing th ornt, I hereby certijv that the we/1(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC'A(`02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ZlNo copy of this record has been provided to the mel/oumer.
1/7lus is a repair,Jill out known uvell construction information and explain the nature of the
repair under 21 remarks section or on the back q/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.
F'or 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: 18 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple ire/Is list all depths ifdiJJereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
/fwater level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Iniection 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.e.auger,rotary.cable,direct push,etc.)
Division of Water Resources,'Linderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield m Method of test: lac.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this forth 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 201?