GW1-2022-08688_Well Construction - GW1_20220419

WELL CONSTRUCTION RECORD E
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: f
14.WATERZONES
Virgil Wilson
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4473 ` CE 9V/�� ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a MATE Hcable
�^�^
Y L' L FROM TO DIAMETER THICKNESS RIAL
Parratt-Wolff, Inc. An• ft. ft. in.
Company Name 1'1 R Prococ Q 16.INNER CASING OR TUBING(geothermal closed-loop)
` (I1f ^t� FROM TO DIAMETER THICKNESS MATERIAL
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2.Well Construction Permit#: V• ,•U 0 ft' 3 ft- •020 '" sch40 PVC
List all applicable well pernil.s(i.e.County,Slate, Variance,hyeclion,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 3 It, 18 ft, 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tr. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑lrrigation 1 ft. 2 ft- Bentonite Chil Tremie
Non-Water Supply Well:
ft. ft.
M Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery � ❑Salinity Barrier
2 ft 18 fL #ZSand Tremie
❑Aquifer Test ❑Stormwa[er Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets:if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soit/mck type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4-5-22 MW-18 ft, ft,
4.Date Well(s)Completed: Well ID#
fr. 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,Certification:
(ifwell feel&one lat/long is sufficient) _
35.866376 N -78.799701 W '`�• �'
Signature of rtified Well Contractor Date
6.Is(are)the well(s): OPermanent or []TemporaryBy signing do. lorm,1 herehi,cerlt&their the ive l(s)wras(were)constructed in accordance
wilh 15A NCAC 02C.0100 or 1 SA NCAG 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy gfihi.s record has been provided to lite reel'owner.
!/this is a repair,till our known we/I consiruclion in(ornialion and explain the nature of the
repair tinder 21 remarks section or on lite back ol'this farm 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 muhiple inieclion or non-nwler supply irel/s ONLY with the same construction,you can _
submit one fount. 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 muhiple we//s list all depths ifdifferent(example-3 cr 200'and 2@ 100') construction t0 the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
U rarer level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
1.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: HSA construction to the following:
(i.e.auger,rotary.cable,direct push,etc.)
Division of Water Resources,,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
4
m 13a.Yield(gp ) Method of test: 24c.For Water Supply&Injection Wells:
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.
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Fount GW-I North Carolina Department of'Environment and Natural Resources-Division of Water Resources Revised August 201?