GW1-2022-07538_Well Construction - GW1_20220815

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WELL CONSTRUCTION RECORD For Imernal 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. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Bcable
FROM TO DIAMETER I THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I n.
Company Name 16.INNER CASING OR TUBING 6mothermall closed-loop)
FROM TO DIAMETER THIC",FSS MATERIAL
2.Well Construction Permit#: 0 ft• 26 ft• 2 '" sch40 PVC
List all applicable well permits(i.e.('aunty.State,Variance,Injection,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 26 fL 36 ft. 2 in.' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. i"•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 f" 22 ft. Portland Cem Tremie
Non-Water Supply Well:
22 ff• 25 It- Bentonite Chil Tremie
OMonitorint=- ❑Recoven'
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
., FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
25 ft. 36 ft. #2 Silica 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/rock e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft. _-1
6-16-22 MW-22 r�
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. AUG 1 v2022
Orange County ft. ft.
Facility/Owner Name Facility ID4(ifapplicable) ft. ft. p?k,10MOG
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)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one lat/long is sufficient)
36.094711 N -79.107686 W -7 (� a
Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): IZPermanent or ❑Temporary By signing This form, 1 hereby certin,that the nreN(s) was(here)constructed in accordance
with ISA NCAC'02C.0100 or 15A NC'AC 02C.0200 Well C'onsiructton Standards and that a
7.Is this a repair to an existing well: ❑Fes or ElNo copy gfthis record has been provided to the well owner.
it this is a repair,fill out known well construction in/brntaiton and explain the nature of the
repair under=21 remarks section or on the back g/'this fbrm. 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-,rater supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple,cells list all depths i/'differeni(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: (fL) Division of Water Resources,Information Processing Unit,
/ftrater 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 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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. I
Fonn GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013