GW1--05833_Well Construction - GW1_20230901

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 8.07 ft 16 ft I I Wet
4473 -- ft. ft. i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft, ft in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO _ DIAMETER _ THICKNESS MATERIAL
2.Well Construction Permit#: N/A 0 It. 6 ft- 2 1°' sch40 pvc
List all applicable well permits(i.e.County,Slate,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 6 ft. 16 ft 2 1°' 010 sch40 pvc
▪Geothermal(Heating/Cooling Supply) ❑Residential Water Supply ft. fL in.
PPY) PPY
❑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:
(]Monitoring ❑Recovery �_ ft. 2 IL Portland Cem Poured
Injection Well: 2 ft. 4 ft Bentonite Chil Poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
4 ft• 16 ft' #1;Sand Poured
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
0 Experimental Technology 0 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.
7-12-23 M W-22 ft. ft p-,_, F .
F .
4.Date Well(s)Completed: Well ID# r
ft. ft. �s w...L.C.: VC.Li
5a.Well Location: ft. ft.
City of Raleigh ft. ft. S E P 1 2023
Facility/Owner Name Facility ID#(if applicable) - t
ft. ft. In orfr'�atiz:n)fc-t' �a5: a u?
1014 N West Street, Raleigh, 27603 ft. fL i;Y;w��`
Physical Address,City,and Zip
21.REMARKS
Wake 1704538007 4"Stick up
County Parcel Identification No.(PIN) 4 Bollards(3")
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) ,
35.78999 N -78.64327 w (P �\ }J \S C� .&' o ' a3
Signature of Certified Well Contractor Date
6.Is(are)the well(s): lPermanent or ❑Temporary By signing this form,1 hereby certfy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1.5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or I?No copy of this record has been provided lo,the well owner.
1f this is a repair,fill 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 of wells constructed: 1 construction details. You may also attach additional pages if necessary.
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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: 16 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/Is list all depths if dierent(example-3@200'and 2 a 100') construction to the following: '
10.Static water level below top of casing: $'07 (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: 8 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of tliis form within 30 days of completion of well
12.Well construction method: HSA construction to the following: i i
(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 m Method of test: 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this foram within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county liealth department of the county where
constructed. 1
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Relsources Revised August 2013
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