GW1--01904_Well Construction - GW1_20240325

WELL:togMitutTIOISIliktiltiV .
for Internal Use ONLYi'
This form can be used for sitile,or multiple'wells ' GWI 01.0 - .
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1.Well dontraetor InfOrmatitiii: •. '
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Vit911 Wilsoq :14.WATER'ZChNES v :. ",' 1 '..."? I '; ' " ... •" '; •
FROM : TO - 'DESCRIPTION . .
Well Contractor Name
* [,--- : - - '' "..-' fi-`-'T. . . ft; ft. , •
:',.. 'k.:6;i,,,,,i,•,`,'Ck_. 47., ,! • - 1 1
44/.3A -fi: ft:.......
NC*elf Contractor Cerlifinntion Number MAR 2 ii 20Z4 '"IS:OUTER CASING((or multi aied wells)OR LINER(If ap- 'cable)
FROM 'TO "DIAMETER :THICKNESS' ' MATERL11
Pattatt-Wolff, Inc. ifLvir4;.'7•71 P:-7-ce,r1 1)7 X "k " k. 1. •!jii.
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CMiip-atiNeme. D'..,NC,..;..3 OG' - 16.INNERCASING OR TURINGfacoilfeitnal ciased•forin)• : 1... ,•
, FROM_ •TO -DIAMETER - THICKNESS'. MATERIAL
2.Well Construction Permit tit • -• 0 it 37:5- ft, .2 . j I:ft!'• Oh•40 • pile
List all applicable well ponnk:s-(i.e.Om:v.:State,Variancednfeciio eic) ' -
ft. ft. ir!,
3 ytrOlf,Use(ch ec4 well fise)! '17:SCREEN
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Water Supply Well: .•.-. FROM- -TO' • DIAMETER- .,SLOT SIZE -THICKNESS 11 MATERIAL
ClAgriatiltural EMuitidipal/Public 27.5, ft -87:5.: •f!!. 2- n.t .010' . .66h40 ., .
PVC
,
. . .. : • , in..
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PGeOilIP741 aidll.008i.c001418' upPly) 1;4e.s.idqP0.0 Water:SlIPPly(single)ld) ft ft „ •
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OInclitStrial/cOrithiethial :0 Reildetitial Water Supply(shared) 18:-GROUT' ... • . . : ,.. . .....
mum - • TO ,MATERIAL .EMPLACEMENT METHOD&AMOUNT
011TigE' D10II . ft. ft: , '
•- 1 . Treitiid .
1,16n4Wrter.SupPly.Well:
4
ft: -* ft' - ,2,•••• ' Trerrtie7--
°MonitiTting -11Reetittery.
ll; 1:, I
InieetiouW „ ft.eIl; .
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tlAquifer flochatse. °OroundWater:Remediation .19:SAND/GRAVEL•PACKiff applicable) ''' ..• .'
FROM TO ' MATERIAL • EMPLACEMENT METHOD '
C144(11ferStorage'atid ReeMietY "13alinity 13afrier
200 it 38.5 ft,. -
'#.1 S0t10 Tretnie .
'ciAgiiifei'reit. °Stofinwiter.Drainage
it., ft, • - -
°Experimental Technology °Suhsiclenee Control -''- -i , - •
.„ _. 20.DRILLING LOG.(attachadditionaLsbeets if necittsitrY).
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Oqetithermal(Closed Loop) DTracer FROM . TO - 'DESCRIPTION(color biidness.seiVraik 40,,giain she,etc.).. .
bOeOtheithaf(i-leatini/tdolidg Return) °Other(eknhiiii iindeili2.11eitiatki) ft,' - ft.^ ' : •
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• ' ' .W--Mt-- - .,.._.
4.Date'Welks)Completed:.. - ..1/10/24.. ••Well II7411710- : -ft.' ft, . 17::';'‘
5a.-Well Location: ft. 'ft: • . ---'?, ' - t,-.?.,.:.
KANE REALITY CORP •
ft. fi. • r i--.; -• - -
' Lb .16. ay/4
FiCiliti/Owneikkiine'. •
Facility ID#(if applicable): • If. ft . '4147...rir.i:gfeti P - - - '
4$21. Lasiteti North•Hills::AVo.Aaleiptc:27609 . • . frglarr,,••-•;,"Lf;...,
,... . ..... . ft ' ft. DWO3a0G
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Physical Addressi:dty,and Zip 2! REMARKS
Wake. . .
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County Parcel Identification No.(PIN) . - ...
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$ii,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: n.,.-- •iiii6iiiiin:
(if well fietd;eirelatlf9tig is,sUffielent) ..'„ 2.. : ' • ". - .r
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W-'"$ -- ' (II.-
gr'rald
• Si of CertifiedWell Contractor . . .. Date
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-'- 6:1i(al)"thiicii(s)•'OPekinineitt.' or Oteiti-poi.ary ... _.... .• _ . _ . . . , _ . _ . ....
By signing'thiS:Prowl ViihiCerib5i-that:die Weil(C)4iiS(wO're)CigiStiiicied in diciiiilao-c;
with 15A NCACO2C:iitao.CrisA Nple.dc,040 WelitoiiStrodlod standards'mid that a
1.is this a:repair to an existing well: .°Yes- or ElNo copy of this record has been provided tCithi well.°mar.
tfthis;:iiO ri:POiry fillthit koCirri*11 ColiSOICtiOtitifolOiatIOO:ciOd.c4lolo;:ilic:fiOturC()Pic- .-.. .. . I:
repOi,r;wider#21 reOjOrkiSeCtiop pi Oligickrieko:riblifor4: ' 23.:Site diagram or additional well'oletaits:
-- You Mk',-tiSelite:liack'ot this page. to provide additioattlWellSite',lietaiis or Well 8Number of wells constructed ;
constructiondetaili. You may attachadditiOnal pages it netegiaty.
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ifor'mdflAtc:iiijoctiOO orilioft•W-rocr supply*Ils.ojgr y#1.!'thg-stin!CCOit*ridi*you CO , - ., • - • - : l',
subiliii.doeforrii; . §i.iBmItrAtiNstutifotiis.-;
9 Total well depth below land iurfaci
. . 3t:,6 (ft) 24it. For Ail Wells: Submit this form within 30 dayx..pf-..completion of well
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For onthifilo wells list oft dePilie Offcreni(examplo-3p2oo.ond-2@l00') construction to the.following.. .'I
Division of Water Ripciiiiea;Information enitt. •
10.Static water level bilikii;.top,of&aging:,none (ft.)
•Ifw.Oierloiid iiaboye cadnE,trio"-" 1017,Mail ServiceCe filer;Raleigh,..$6218*1517
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II,Borehole diameter 8 (in) 24b."For litiention Wells ONLYi In addition to sefidint,the form to the-address in
24a abcitie,:algO ittbniii a:copy otthiX'font' within 30 day'S'of'Cott pletion of Well.
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I2.Well construction Method:-- .Hand•'• -• , .auger, H8A- construction to the follot:ving:-. I,
(i.e.augert.roiary,cable,direct push etc.) i'_ .. • .
DiYiskift.Cof WgtetReoittees,Underground Injection Control Program,.
' FOR WATER SUPPLY WELLS ONLY:. . . 16361Mail Service'(enter;Raieigh,-NC-27690.71636
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• 24e:.For.Wa ter ttippiy.k Injectitnif‘YellS:
la..Yield.(gptri)• 'Method,of test:
Also -siihrtiii'One:onny.otiliis fqtni Yiithiii.30 dit5*0T6'.)thiti.le!i0if of
15b.:Disinfeetion type; :Amount: .well construction to the county health:department of the county where
. constructed. .i. '
Fenn OW-I 146411"canaline Depariaiettt iitEMi incl:internand NatUMIEenifineS DiriiionnfWatei Resources ',le..*idAtftia'at'201