GW1--01551_Well Construction - GW1_20240308

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 ft. ft 1
4473A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS 1 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 '"• 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 65 ft. 70 ft. 1 1°' .010 sch40 pvc
EGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lirigation - 1 -ft:- . ______ft.: -
Non-Water Supply Well:
36 Portland Cem Pour
❑OMonitoring ❑Recovery 36 ft 38 ftBentonite Chil Pour
Injection Well: 51.5 ft 63 ft Bentonite Chil Pour
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 38 ft 51.5 ft #1 Sand Tremie
❑Experimental Technology ❑Subsidence Control 63 ft 70 ft #1 Sand Tremie
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. ,
1/11/24 MW-20 D ft. ft.
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft C 7 4 M�Z ki F
KANE REALITY CORP ft ft. • t� �a�' 0 S rq
Facility/Owner Name Facility ID#(if applicable) M ARZUL4
ft ft.
4321 Lassiter, North Hills Ave.,Raleigh 27609 ft ft
Physical Address,City,and Zip 21.REMARKS )(}`, .:f=�'v' -1. Jr^` `� `"'^���
t,;y..v,-'1."
Wake C =
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.�^ertifrcati n:
(if well field,one lat/long is sufficient) {
35.8357309 N -78.6438744 W \,► t 02 ' ig'ay
Signature o Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signin this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or iSA NCACO2C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or lNo copy of this record has been provided to the well owner.
If this is a repair,full 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
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 ifdifferent(example-3 a 200'and 2@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 Injection Wells ONLY: In addition to sending the form to the address in
HSA 24a above, also submit a copy of this form within 30 days of completion of well
Hand auger,
12.Well construction method: construction to the following: ,
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resource ,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
13b.Disinfection type: Amount well construction to the county liealth department of the county where
constructed. 1
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013