GW1--05836_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 11.52 ft. 17 ft. I I Wet
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. 7 ft 2 , i"• 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 7 ft. 17 ft. 2 in. 010 sch40 pvc
❑Geothermal(Heating,/Cooling Coolin Supply) ❑Residential Water Supply ft. ft. in.
( P� g 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: --- --
OMonitoring ❑Recovery 2 ft. 3 fL Bentonite Cer Poured
Injection Well: 3 ft 5 ft Bentonite Chi!Poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Storage and Recovery ❑Salinity Barrier 5 ft. 17 ft. #1 Sand Tremie
: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.
ft. ft.
4.Date Well(s)Completed: 7-11-23 Well ID# MW-23 fL ft. i' '" Iw 't
R F. ,.t- pV E L.
5a.Well Location: ft. ft.
City of Raleigh ft. ft. SEP i) 1 2023
Facility/Owner Name Facility ID#(if applicable) ---
ft. ft.
1014 N West Street, Raleigh, 27603 to�'ry '` P` *�`g Lrfi
ft. fL rab
D ,
Physical Address,City,and Zip -
21.REMARKS
Wake 1704538007 24"sonotube
County Parcel Identification No.(PIN) 4"stick up/Four 3"bollards
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) 1
35.790870 N -78.643915 N, q lCZ,S 1 >` (.\ `- . I c)•�,
Signature of Certified Well Contractor ' Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,/hereby certify that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 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
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.
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: 17 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list a//depths if different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 11'S2 (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 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.) j
Division of Water Resources,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. I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013