GW1-2022-07485_Well Construction - GW1_20220810

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I`
I.Well Contractor Information: I
Gary Ellingworth 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I
3367
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased;wells OR LINER if a ticable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. 0 ft. 11 ft- 6 in SCh40 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 115 ft. 2 in. SCh40 PVC
List all applicable well permil.s(i.e.Cotmty.Slate,Variance.Injection,etc'.(
fr. I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 tr' 20 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Su Iy(single) ft. ft. in.
( � g PP Y PP ( g )
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 1. 11 fit- Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 0 ft. 11 ft. Portland Cem Tremie
Injection Well: 11 fL 13 ft. Bentonite Chil Tremie
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 13 f1. 20 ft. #1;Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,grain sin,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. R.
ft. tt.
4.Date Well(s)Completed: 7-22-22 Well ID# MW-141 fr. fr.
5a.Well Location:
Piedmont Rescue Mission Inc ft. ft 10(crvnlilUon PrOG66
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
1612 Hilton Road Burlington ft. ft.
Physical Address,City,and Zip
21.REMARKS
Alamance 139485 8"FMC
County Parcel Identification No.(PIN) 2'Pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one[at/long is sufficient)
36.099685 N, -79.410270 W. a-
Signature of�Cl"fie"
d Well C ntractor Date
6.Is(are)the well(s): (OPermanent or ❑Temporary By signin , 1 herehv cernr' that the well(s) was(were)constructed in accordance
with 15A NC .0100 or I.iA NCAC�02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy oftli.s record has been provided to the well owner.
IJthis is a repair,Jill an known well construction information and explain the native of dte j
repair under 21 remarks section or on the back g1this Jhrm. 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.
For multiple injection or non-water supply wells ONLY with the same construction,von can
submit oneJorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor muhiple wells list all depths tJ'diljerem(example-3@200'and 2 a.100') construction to the following:
10.Static water level below top of casing: unknown (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: 2 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
24aabove, also submit a copy of thisjfonn within 30 days of completion of well
4 1/4 HSA,2"split spoons;8 114 HSA,6"pvc,6"Air Rotary
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center ti ,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 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 of Water Resources Revised August 201