GW1-2022-06796_Well Construction - GW1_20220715

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
' 1.Well Contractor Information:
I I
Mike Tynan :o14.WATER'ZONES , ..
Well Contactor Name FROM TO DESCRIPTION
2725-A 20 ft. 32 ft• pwr
ft. ft. I ,
NC Well Contractor Certification Number 135:,OUTER VASING form ulfi,casedl.livells OR LINER"if u '`Gentile
IET (Innovative Environmental Technologies) FROM TO DIAMETER THICKNESS [MATERIAL
fr. ft. in.
Company Name ��0 0 0
'[6,INNER C'ASING'OR TUBING=
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 17 ft. 2 in' 1 SCh40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS I MATERIAL
Agricultural E)Municipal/Public 17 ft. 32 fL 2 in. 0.010 Sch40 JPVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
Industrial/Commercial QlResidential Water Supply(shared) 18.GROUT.
lrri ation FROM TO .,. MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 3 ft. concrete pour
_ x mo-nitoring___.__ ______— ORecovery _ _ _ _ _ 3- _ft,__15---ft- bentOte';— -pour- — -- —---
Injection Well:
ft. ft
Aquifer Recharge OGroundwaterRemediation 19.'SAND/GRAvEL`P.ACK ifa 'lica6le
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 15 ft. 32 ft #2 silica sand tremie
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) [ITracer ,t20.,DRILLINGiLOG,attach'addiHonal`sheets ifnecess
Geothermal(Heating/Cooling Return) ' Other(explain under#21 Remarks) I
FROM I TO DESCRIPTION(color,hardness,soilfrock type rain sae,etc.
0 ft. 10 ft- silty sand
4.Date Well(s)Completed:7/5/22 Well ID#M W 10 fL 18 ft. light brown Pwr
5a.Well Location: 18 ft' 28 ft, light grey pwr
Self Help Ventures Fund 28 ft. 32 ft. light brown pwr .��
Facility/Owner Name Facility ID#(if applicable) ft. ft. y.
906 Carroll St, Durham, 27701 ft. ft. 5
Physical Address,City,and Zip ft. ft. '
:21.'REAfARK5 1
x rem; :?
Durham
County Parcel Identification No.(PIN) MW completed at surface with flush covet; `' �s '1 I,
1'
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: concrete pad. i
(ifweG field,one lat/long is sufficient) 22.Certification:
35.992656 N 78.916490 W
/ 7/10/22
6.Is(are)the well(s)ix permanent or OTemporary Signature ofCe • ed Well Contractor Date
By signing this form,I hereby cert fy that the well(y)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or x)No svith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copv of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this form.
23.Site diagram or additional well details: '
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS�
9.Total well depth below land surface: 32 (ft-) 24a. For All Wells: Submit thisi form within 30 days of completion of well
For multiple ivells list all depths ifdierent(exannple-3@200'and 2@100') construction to the following: I
10.Static water level below top of casing:—20 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service enter,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Auger &Air Rotary above,also submit one copy of thiis form within 30 days of completion of well
(i.e.anger,rotary,cable,direct push,etc.) construction to the following: I
Division of Water Resources,U Iderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Genter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SUDuly&Iniectio I Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016