GW1-2021-03632_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Todd Muench 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 4 ft- 8.5 ft' wet
3371
i
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. rt. in.
Compam Name 16.INNER CASING OR TUBING 2 eothermal closed-loop)
WM0501446 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 8 5 ft. 1 1°' SCh40 pVC
List all applicable well perndts(ii.e,Counlr,Stare, f'ariance,I teclion,etc.)
fL ft. in,
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in:
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supplv(shared) 19,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 5 ft. 1 ft- Bentonite Chil Tremie
Non-Water Supply Well:
ft. ft.
[OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemedialion 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft•
❑Aquifer Test ❑Stormwater Drainage 1 r" 8.5 #1 Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
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) 0 ft. 1 ft. Asphalt
1 ft. 5 ft. Brown, moist,silt/clay with sand/gravel
�.Date Well(s)Completed: 8-4-21 Well ID#TW-1
5 rt. 7 ft. Brown,dense, moist PWR
5a.Well Location:
ft. ft. 41
AP Brightleaf Square Owner LP u
rt. ft.
Facility/Owner Name Facility IDk(ifapplicable)
ft. ft.
823 West Morgan St, Durham 27701 ft• ft• A urti►t
Physical.Address,City,and Zip
21.REMARKS
Durham 0821-07-69-7269
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Cer' cation:
(if\veil field,one lot/long is sufficient) `
36.000731 -78.909574 �
SignatureofCertified ell Contractor Da
6.Is(are)the well(s): ❑Permanent or ©Temporary BY signing this orm, 1 herebv cerli that the wells was(were constructed in accordance
g g ! h (1 )
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 El No copy gl'this record has been provided to the well owner.
1/this is a repair,fill out known well construction iolbrnration and explain the name g17he
repair under=21 remarks section or on the buck o/this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary_.
hor multiple injection or non-waler.supply wells ONLY with the same construction,you can
submit one 1brm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 8.5 (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
h'or multiple wells list all depths it'di/Jerenl(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 4 (ft.) Division of Water Resources,Information Processing Unit,
4 water level is above casing,use" - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
DPT225 24a above. also submit a copy of this form Within 30 days of completion of well
.
12.Well construction method: construction to the following:
(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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days ofcompletion 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 of Water Resources Revised August 201?