GW1--05837_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 6.2 ft 29 ft
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 hi: N�A o ft. 19 ft. 2 l i" 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 19 ft. 29 ft. 2 i" .010 sch40 pvc
ft. ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(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:
Monitoring ❑Recovery 1 ft• 15 ft Bentonite Cer Poured
Injection Well: 15 ft 17 ft Bentonite Chii Poured
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
17 ft 29 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) ElTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft. 1
7-18-23 ft. ft. i
MW-25 D
4.Date Well(s)Completed: Well ID#
ft. ft �--
5a.Well Location: ft. ft. l'.. �P L..i 1V --L'
City of Raleigh ft. ft. Sq
Facility/Owner Name Facility UN(if applicable) F P J 1C_023
ft. ft
1014 N West Street, Raleigh, 27603 ft ft 'nil:::n ?t..:..• •-...:.a i,1“,.
Physical Address,City,and Zip r1b'.t^t 0;'
21.REMARKS
Wake 1704538007 8"FML in black top
County Parcel Identification No.(PIN)
i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification•
(if well field,one lat/long is sufficient)
35.790073 N -78.64296 w \ l 2 S N -c - •(d -.),,
Signature of Certified Well Contractor ; Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Contruction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IENo 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 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 same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 29 (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 a t00'and 2@100') construction to the following:
10.Static water level below top of casing: 6'20 (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 I
(in.) 24b.For Infection Wells ONLY: n 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
(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 form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county Iiealth department of the county where
constructed. I
Fonn GW-I North Carolina Department of Environment and Natural Resources-Division of Water,Resources Revised August 2013
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