GW1--05831_Well Construction - GW1_20230901

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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:
Virgil Wilson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 18.76 ft- 33 ft-
4473 ft. ft. I 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS 1 MATERIAL
Parratt-Wolff, Inc. ft. ft. 1 'in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A 0 ft. 23 ft. 2 ' in. sch40 pvc
List all applicable well permits(i.e.County,State,Variance,injection,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 23 fr. 33 it. 2 in. 010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply ft. ft. in.
( � g PP Y) PP Y(single)
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 1 ft. Concrete Poured
Non-Water Supply Well:
1 ft. 19 ft- Bentonite Cer Tremie
❑O Monitoring ❑Recovery
Injection Well: 19 ft- 21 ft- Bentonite Chi!Poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑
21 ft- 33 ft- #1 Sand Poured
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
' a
7-18-23 MW-29 D ft. ft. _ ;I( .I^.11 L L
4.Date Well(s)Completed: Well ID# -
ft. ft-
�
Sa.Well Location: ft. fft. SEf 0 1 !LULJ
City of Raleigh ft. ft. ••
Facility/Owner Name Facility ID#(if applicable) to vr"f
ft. ft. DWC1;3'i-4
1014 N West Street, Raleigh, 27603 ft. ft.
Physical Address,City,and Zip ' - - - - -- - ---
21.REMARKS
Wake 17045380074' Stick up
County Parcel Identification No.(PIN) 4 Bollards(3")
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. ertification: 1
(if well field,one lat/long is sufficient)
35.79372 N -78.64246 W <9.__c& L\S, g ' (d .
Signature of Certified Well Contractor : Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(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 ONo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction it formation and explain the nature of the
repair under s21 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 of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For 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: 33 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@i00') construction to the following: ;
18.76 Division of Water Resources Information ProcessingUnit
10.Static water level below top of casing: (ft.) ,
If water level is above casing,use"4-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (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: i-I.SA 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 Cei ter,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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.
Fonn G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013