GW1-2022-07537_Well Construction - GW1_20220815

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 ft. ft. f
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells)OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. in.
Company Name 16.INNER CASING OR TUBING(geothermal elosed-loo
FROM I TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 15 ft. 2 i" SCh40 I PVC
Li.ci all applicable well permits(i.e.Coun(n,Slate.Variance,hileclinn,etc.) .
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft' 40 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
[Irrigation 0 1. 11 rt. Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 11 ft 13 ft Bentonite Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
13 ft 40 ft #1 Sand Tremie
❑Aquifer Test ❑Stormwa[er Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRELLING 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 421 Remarks) ft. ft.
4.Date Well(s)Completed: 6-20-22 well ID# MW-21 ft. ft. rt"A I
C+
ft. ft.
5a.Well Location: ft. ft. 1 r s
Orange County ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. " UFA
195 Torain Street, Hillsborough 27278 ft. ft.
Physical Address,City,and Zip
21.REMARKS
Orange 9865735223 2 x 21Concrete Pad
County Parcel Identification No.(PIN) No Protective Casing
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field one[at/long is sufficient)
36.097262 N -79.107433 W. . ,/` -7 a o�
Signature ofieenified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing dus farm, I hereby certifi+dial the well(s)+was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Slandards and that a
7.Is this a repair to an existing well: ❑Yes or E]No cony ofihis record has been provided to the well owner.
1/'this is a repair,Jill out known well construction information and explain the nature o(dre
repair under=�21 remarks section or on the back q(this/brm. 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-waler smpply wells ONLY with the same construction,von can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 40 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells list all depths ifdt/ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Res lurces,Information Processing Unit,
1/water level is abore casing,use " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy ofl this form within 30 days of completion of well
12.Well construction method: HSA construction to the fallowing:
(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 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 2013