GW1-2022-08692_Well Construction - GW1_20220419

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
L Well Contractor Information:
Virgil Wilson 14.WATER ZONES r
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4473 EE C �`�� D ft. ft.
NC Well Contractor Certification Number r 15..OMER CASING for multi-cased'wells'OR LINER if ap licable
AIR sQ Zf122 FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. PR V l0 ft. I in.
Compan}Name e' 16.INNER CASING OR TUBING(geothermal closed-loo)
jn;OfiBtSawtxl�rI1C�,S:?6It�ufS� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: D IC1100,13 ft. ft. ; in.
0 3 .020 sch40 pvc
List all applicable well permits(i.e.Couniv.State,Variance,Injection,etc.)
f[. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 f`' 18 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 1 ft. 2 fit- Bentonite Chii Tremie
Non-Water Supply Well: ft. ft.
RI Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if i licslble
FROM TO MATERIAL EMPLACEMENT METHOD wN
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 ft. 18 f` #2 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING`LOG atfiii64ddiiionalistiebts if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock rfpe,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 4-6-22 MW-23 ft. ft.
Completed: Well ID# ft. ft.
5a.Well Location:
ft. ft.
Raleigh Durham International ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) 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: Vu)
'
n•
(ifwell field,one[at/long is sufficient) f
35.866801 N -78.799714 W - 1 •�a
Signature of rtified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hy signing this.1brm,I hereby cerlijv that the we/l(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 ZlNo copy gfihis record has been provided to die well owner.
lj'thi.s is a repair,till out known well construction information and explain the nature o(the
repair under=21 remarks section or on the back o/'thi.s%arm. 23.Site diagram or additional well details:
You may use the back of this page,to provide additional well site details of 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 wuh the same construction,you can
submtl one Jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 18 (ft.) 24a. For All Wells: Submit this-form within 30 days of completion of well
1-"or multiple wells list all depihs if difjereni(example-3@200'and 2 a l00') construction t0 the following:
10.Static water level below top of casing: (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: 2 (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: 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
13a.Yield(gpm) Method of test: 24c.For Water Supply&In,jection4ells:
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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Form GW-I North Carolina Department of Environmmril and Natural Resources—Division of Water Resources Revised August 2013