GW1--01090_Well Construction - GW1_20240216

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information: ' -
Virgil Wilson 14.WATER ZONES
g FROM TO DESCRIPTION _
Well Contractor Name
ft ft. 1
4473A ft. ft. i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
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#: 0 ft. 65 ft. 1 1°' 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 -
EAgricultural ❑Municipal/Public 65 ft. 70 ft 1 1O' 010 sch40 pvc
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 1 ft• 36 ft• Portland Cem Pour
Ion-Waterupply-Well:
❑OMonitoring ❑Recovery 36�ft' -38 ft; Bentonite Chi(Pbur
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL 1 EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier .
38 ft' 51.5 ft' #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
I OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
1/11//24 MW-20 d ft. ft.
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. §''d yea. ��. e L.4 VE,L
KANE REALITY CORP
Facility/Owner Name Facility lD#(if applicable) ft. ft. F l-f1 P �6
ft. ft. •
4321 Lassiter, North Hills Ave.,Raleigh 27609 fL ft. h'l.vrn"tr^ tc^,n vrr.�,yccie;WO
Physical Address,City,and Zip . Dt4Ai etas°`
21.REMARKS
Wake
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) L
35.8357309 N -78.6438744 W t t -l✓/ /�----If • a - , a A`-(
Signat re 6f CertifieydiWell Contractor Date
6.Is.(are)the well(s): ©Permanent or ElTemporary By:signink this.forn,1 hereby cerfifi,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 information and explain the nature of the
repair under 421 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 1
9.Total well depth below land surface: 70 (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 200'and 2 a 100') construction to the following: j
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 8 (in.) 24b. For Injection Wells ONLY:) In addition to sending the form to the address in
Hand auger, HSA 24a above, also submit a copy of this form within 30 days of completion of well
construction to the
12.Well construction method: following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm) 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: 24c.For Water Supply&Igjecti In Wells:
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.
Fo tt W-1 North Carolina Depamnent of Environment and Natural Resources-Division of Water 2 Resources Revised August 2013