GW1-2022-07487_Well Construction - GW1_20220810

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells j
L Well Contractor Information:
Virgil Wilson FROATERZONES DESCRIPTION
Well Contractor Name ft. ft.
4473 f` f`.
NC Well Contractor Certification Number 15.OUTER CASING for mWti-cased wells OR LINER if a licable
FROM TO DIAMETERI THICKNESS MATERIAL
Parratt-Wolff, Inc. 0 ft. 23.5 ft- 6 i1 SCh40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 40 ft. 2 in. SCh40 PVC
List all applicable ire0 permits(i.e.County.Slate,Variance,Injection,etc.)
f[. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 40 ft' 50 f[' 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑irri ation 0.5 ft' 26 ft. Portland Cem Tremie
Non-Water Supply Well:
26 ft- 28 fr. Bentonite Chil Tremie
OMonitoring ❑Recovers
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft, ft.
28 51 #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sbeets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 7-29-22 MW-140 ft. ft.
$)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. r
Norton Ronald Lee ft. ft. AUG s 0 20
22
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
1708 10, Hilton Road Burlington ft. ft.
D
Physical Address,City,and Zip 21.REMARKS
Alamance 139768 8"Fnnc
County Parcel Identification No.(PIN) 24"Sonotube
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Urtificatio
(if well field.one IaJlong is sufficient)
36.099685 N -79.409132 W �k
7 . �� a a-
Signature ofC tied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary gy signing/his/brm, 1 hereby cerli(v that the irell(s)was(were)constructed in accordance
frith 15A NCAC 0X.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or [Z]No copy gl'this record has been provided io!the well owner.
If this is a repair/ill out known well construction information and explain the nature q/the
repair under 21 remarks.section or on the back q/'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.
For multiple injection or non-waier.supply wells ONLY with the same construction,van can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1�ar multiple wells list all depths ifdifjereni(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,
if water lerel 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
4 1l4 HSA,2"split spoons;8 114 HSA,6"pvc,6"Air Rotary 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
I
13a.Yield m
(gP ) 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 It ealth department of the county where
constructed.
. i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water f Resources Revised August 2013