GW1-2021-00249_Well Construction - GW1_20210125

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATERZONES
Virgil Wilson •
FROM TO DESCRIPTION
Well Contractor Name 13.35 ft. 25 ft. ! Wet
4473 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fr. 15 ft. 2 i" SCh40 PVC
Liss all applicable hell pernal.s(i.e.Conn iv,Stale, Variance,Injection,etc.) ft. ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 It. 25 ft. 2 in.'' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply ft. rr, in.
PPY) PPY
❑Industrial/Comm ere ial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 11 ft- Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 11 fr 13 fr Bentonite Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO ft MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑ 13 ft' 25 #1ISand TremieStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Con Vol 20.DRILLING LOG(attach additional sheets ifnecessa'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 12/21/20 DU-MW-05R ft. ft.
$)Completed: Well ID# rt. fr.
5a.Well Location: ft. ft.
Exxon-Mobil-VCC ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
2714 Angier Avenue, Durham NC 27703 ft. ft.
Physical Address,City,and Zip
21.REMARKS
Durham 4"Procover w/24';'sonotube and 3 bollards
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 ftification:
(if well field.one tat/long is sufficient)
35.58585 N -78.52226 w. a�
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Qv signing this fornn, I herebv cerlilD that the nrell(.$)was(were)constructed in accordance
with 15.4 NCAC 02C.0/00 or 15A NCA'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy q/'this record has been provided to the me//owner.
Ijlhis is a repair,Jill au known we/1 construction itgformalton and explain the nature of the
repair under-21 remarks section or on the back o/'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.
Ivor nudiiple injection or non-water supplyire/tv ONLY with the same construction,WVff( )
.submit one lbrm. ,`g , SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 F��, J (f 24a. For All Wells: Submit this!form within 30 days of completion of well
For nndliple ve/ls list all depths ifdt&renl(exannple-3 a 200'all c �O construction t0 the following:
.oo �S'r
10.Static water level below top of casing: 1 3.35 ! .\ (ft C Division of Water Resources,Information Processing Unit,
IJ a-mer level is abore casing,use \ -rP, •. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 246. For Infection Wells ONLY: In addition to sending the form to the address in
12.Well construction method: HSA construction to the b Mowing py of this font within 30 days of completion of well
(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'tWells:
IgP ) 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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division ot•Water Resources Revised August 2013