GW1-2021-03633_Well Construction - GW1_20210823

i
WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple Hells
I.Well Contractor Information:
Todd Muench 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name 5 ft. 7 ft. wet
3371 ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multl-cased,wells OR LINER ifa licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
WM0501446 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 7 et. � i"• SCh40 pvC
List all applicable+rell permits(i.e.Countyt State.Dhriance,htjection.etc*.)
ft. 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
ft. ft.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 5 ft. ft. Bentonite Chil Tremie
Non-Water Supply Well:
O Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier � ft. 7 ft' #1 Tremie
❑Aquifer Test ❑Stormwater Drainage tt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets it 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 R. 1 ft. Asphalt
4.Date Well(s)Completed: Well ID#
8-4-21 TW_2 1 ft. 5 ft. Brown, moist,silt/clay with sand/gravel
5 ft. 7 ft. Brown,dense, moist PWR
5a.Well Location: ft. ft.
AP Brightleaf Square Owner LP ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
823 West Morgan St, Durham 27701 ft. ft. ��
t
Physical Address,City,and Zip
21.REMARKS � •
Durham 0821-07-69-7269 , UM
County Parcel Identification No.(PIN)
C,[r 3
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 5$Aegtion:
(3 veil field.one lat/long is sufficient) /_ Wt
36.000930 N -78.909313 WC,//
l a
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or [OTemporary
/3v signing thus./torn, /herehv c•eniJi%that the+re//(s)uas(were)constructed in accordance
+rich 15A N('AC 02C.0/00 or 15A NC'AC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or lZJNo copv of this record has been provided to the+ref/orner.
//'this is a repair,lilt out known well construction inlbrmation and erplain the nature of the
repair under=21 remark+'section or on the hack ql 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.
f•or multiple injection or non-water supply wells ONLY with the same construction,you can
.submit one firm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor multiple+cells list all depths ifdi#erem(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 5 (ft.) Division of Water Resources,Information Processing Unit,
1/'+rater level is above casing,use" ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection 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
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
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?