GW1--05835_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
9 FROM TO DESCRIPTION
Well Contractor Name 10.11 ft 30 ft I 1
4473 ft. ft.
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 ft' 20 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 20 ft. 30 ft. 2 in. .010 sch40 pvc
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM11 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 1 ft. Concrete Poured
Non-Water Supply Well:
❑O Monitoring ❑Recovery 1 ft. 16 ft- Bentonite cerr Poured
Injection Well: 16 ft 18 ft Bentonite Chip Poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
18 ft- 30 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.
7-11-23 MW-24 D ft. ft.
ft. ...i-
4.Date Well(s)Completed: Well ID# , .(,t'.¢_i; /t.Ls
5a.Well Location: ft. ft.
City of Raleigh rt. ft SEp v i 232 i
Facility/Owner Name Facility IN(if applicable) y
ft ft. • '�r^.C,?t'>?.• Jr1,:..
1014 N West Street, Raleigh, 27603 ft ft tn`'r. : �'I� •°t=:ram `-'
Physical Address,City,and Zip 21.REMARKS
Wake 1704538007 4"Stick up
County Parcel Identification No.(PIN) 4 Bp;;ards(3")
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) '
35.790860 N -78.643313 W ,2-5 �� 6)c�Ckj� - Hd . a3
Signature of Certified Well Contractor ' Date
6.Is(are)the well(s): Its Permanent or ❑Temporary By signing this form[,1 hereby cergjy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or (i7No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the j
repair under v21 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 saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 (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@100') construction to the following:
10.Static water level below top of casing: 10'1 1 (ft) Division of Water Resources,Information Processing Unit,
If water level is ahove 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 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 Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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