GW1-2022-10675_Well Construction - GW1_20221205

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
g";��y a 14.WATER ZONES
Virgil Wilson t
''b # ' FROM TO DESCRIPTION
Well Contractor Name 1 I- ft. ft.
4473 �~ V �. >�ra ft. ft.
NC Well Contractor Certification Number 1` T 15.OUTER CASING(for multi-cased wells OR LINER if li a cable
a a,✓+ ea
gilts vs \I dt�i FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. i in,
Company Name 16.INNER CASING OR TUBING 'eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft- 2 1 i"- SCh40 PVC
List all applicable well permits(i.e.Countv,Slate,Variance,h jection,etc.)
f[. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft' 20 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 EMPLACEMENTMETHOD&AMOUNT
01rrigation 0 f" 6 It. Portland Cen Pour
OMonitoring ❑Recovery 6 ft. 8 ��t• Bentonite Ch Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
8 fr 20 ft #1 Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothemlal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well 10/13/22 s)Completed: Well ID# MW-1 ft. ft.
ft. ft.
5a.Well Location: ft ft.
TForce Holdings USA, Inc ft. ft.
Facility/(honer Name Facility ID#(ifapplicable) ft. ft.
150 International Drive, Morrisville ft. ft.
Physical Address,City,and Zip
21.RE[1fARKS
Wake 8°FMC
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certificati n:
(ifwell field,one lat/long is sufficient) 4
35.834917 N -78.821557 W i 0 ( a
Signature of rtified Well Contractor Date
6.Is(are)the well(s):_14Permanent _or ❑Temporary E3y signing This Jorn,/hereby certify that the we//(s)was(were)consintcted in accordance
with 15A NC'AC 02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofihis record has been provided to the well owner.
!"this is a repair,Jill out known well construction information and explain the nature of the
repair under-.21 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 ofwells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For mithiple it jection or non-woler supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For uuthiple wells list all depths iit ififftreni(example-3@200'and 2@100') construction to the following:
10:Static water level below top of casing: 8 (ft.) Division of Water Resources,Information Processing Unit,
/flvaler lerel is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
4 1/4 HSA 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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
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13a.Yield(gpm) 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. f
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013