GW1-2022-07539_Well Construction - GW1_20220815

I
WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells '.
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Hcable
FROM TO DIAMETER 1 THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM I TO DIAMETER THICKNESS MATERIAL
1.Well Construction Permit#: -0.3 ft' 10 fr. 2 i"' SCh40 I PVC
List all applicable ire//pernuts(i.e.Col oll.State,Variance,Injection,etc.)
ft. I I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft- 20 ft. 2 in'' .010 sch40 PVC
ft. ft.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation _0 3 ft' 6 It. Portland Cem Tremie
Non-Water Supply Well:
MMonitoring ❑Recovery 6 ft 8 ft Bentonite Chi Tremie
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
8 ft- 20 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/mck type,grain size,etc.
❑Geothermal(Heating/Cooling Rewm) ❑Other(explain under 421 Remarks) ft. ft.
ft. ft.
4.Date Well 6-30-22 MW-24s)Completed: Well ID#
5a.Well Location: rt. ft.
Orange County ft. ft. 2@2- -
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 1f1fCfWal ic''l Fi �.�iG3'.E i,h�(�(
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:
(if well field.one lit/long is sufficient)
36.092278 N, -79.109675 W.
Signature of Certified Well Contractor ! Date
6.Is(are)the well(s): [OPermanent or ❑Temporary
l3v signing this form,I hereby certify dial the we//(s)was(were)constructed in accordance
With 15A NCAC 02C.0100 or 1 5A NC'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
lflhis is a repair,fill out known well construction information and explain the nature nfdte I
repair under a21 remarks section or on the back o/this/orm. 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 supp/v wells ONLY+with the same construction,ynu can
submit one jorm. 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
For nn hip/e wells list al/depths i(dt/ferem(example-3 tt 200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
1J water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b.For Infection Wells ONLY:I In addition to sending the form to the address in
24aabove, also submit a copy oflthis 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
m 13a.Yield
(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 health department of the county where
constructed. f
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013