GW1--01091_Well Construction - GW1_20240216

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
g FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4473A ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM ft. ft.
DIAMETER in.
THICKNESS MATERIAL
Parratt-Wolff, Inc.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: - - 0 ft' 40 ft. 2 in• sch40 pvc
List all applicable well penults(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 40 ft. 50 ft. 1 1°' .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
( � g PPY PPY
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 1 ft. 36 ft. Portland Cem Pour
Non-Water Supply Well:
OMoriitorng ❑Recovery - - -- 36--ft. 38--ft_._ BentoniteChi-Pour- = - - _
Injection Well: ft. ft.
['Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
['Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
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.)
['Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
1/11//24 �-MW 20-s--� ft. ft.
4.Date Well(s)Completed: Well II)#=.n-- -.,_-_ i P ft. ft.
5a.Well Location: ft. ft.
KANE REALITY CORP ft. ft. off' -�. ,,...
Facility/Owner Name Facility ID#(if applicable) ft. ft. "t E R` t
4321 Lassiter, North Hills Ave.,Raleigh 27609 ft. ft. rtb ,. t: con.
Physical Address,City,and Zip 21.REMARKS ,
Wake itt,t,;,l,n.tt ::+,h ry::.�.;x,,;,,;4 Uti•.
Gt
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifi ation:
(if well field,one lat/long is sufficient)
3 1- 2 7`4N w- IL -)oozy
-�sV 1�3:��1�
ii^ Si nature ofCertified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary. By signing this.form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A 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- I No 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 2I remarks section or on the back of this fan. 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: 50 (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')100') construction to the following:
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
11.Borehole diameter: 8 (in.) 24b. For Infection 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
12.Well construction method: construction to the following: j
(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(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Amount: well construction to the county!health department of the county where
constructed.
Fonn GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013