GW1-2022-07540_Well Construction - GW1_20220815

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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
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedivells OR LINER if a
FROM TO DIAMETER; ficable THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. fr. in.
Compam Name 16.INNER CASING OR TUBING cothermal elosed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fr. 27 fr• 2 1 "' SCh40 PVC
list all applicable well permits(i.e.Count,Stale. Variance,Ittiection,etc.)
i in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMETER LSLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 27 ft' 37 ft. 2 " .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 ft' 23 ft- Portland Cem Tremie
Non-Water Supply Well:
23 rr. 25 fr. Bentonite Chi Tremie
Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licitble -
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
25 ft• 37 fr #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 lcolor.hardness,soil/rock type,gW2 gm etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. ft. ^ h
4.Date Well 6-30-22 s)Completed: Well ID# MW-23 ft. ft.
R. fr. AUG !
5a.Well Location: fr. ft
Orange County ft. ft.
p;+.�.� r, 0( Una
J:2Z`
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
195 Torain Street, Hillsborough 27278 ft. fr.
Physical Address,City,and Zip 21.REMARKS
Orange 9865735223 2 x 2toncrete Pad
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one]at/long is sufficient)
36.093415 N, -79.107875 W. \k ( S oZ
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Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
Uv signing this form, /herehr'certify dim the Ire//(t)u•as(were)constructed in accordance
frith I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or O No copy of this record has been provided to the we/it owner.
lflhis is a repair,Jill out known well construction info-malion and explain the nature o/the
repair under-21 remarks secvion or on the back o/7hi.s than. 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-u•aler.supply wells ONLY with the same construction,you can
s'ubntit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 37 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths il'diljerenr(example-3@200'and 2 rt 100') COnSttUc[iOn to the follovtiing:
10.Static water level below top of casing: (ft.) Division of Water Res ources,Information Processing Unit,
glrater 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 ofithis form within 30 days of completion of well
12.Well construction method: Air Rotary 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
13a.Yield(gp ) 24c.For Water Supply&Injection Wells:
m Method of test:
Also submit one copy of this foritl within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013