GW1-2022-07547_Well Construction - GW1_20220815

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
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased.wells OR LINER if a ticable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I ; in.
Company Name 16.INNER CASING OR TUBING cothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 17 ft. 2 in. sch40 PVC
List all applicable+cell pertain(i.e.Coun(v.Slate,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 17 ft' 27 ft' 2 in.
.010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supplv(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 14 ft. Portland Cem Tremie
Non-Water Supply Well:
RI Mon itori ng ❑Recovery
14 ft. 16 ft. Bentonite Chii Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicilibliell
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 16 ft. 27 ft' #2 Silica Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionid sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color•hardness,soil/rack type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. r e.
6-30-22 MW-29 ft. ft. ' W "
4.Date Well(s)Completed: Well ID# ft. ft. Y
5a.Well Location: ft. ft.
Orange County ft. ft.
Facility/Owner Name Facility ID#(if applicable)
195 Torain Street, Hillsborough 27278
Physical Address,City,and Zip
21.REMARKS
Orange 9865831888 2 x 2 Concrete Pad
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
36.097669 N -79.108552 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary
By signing this Jorm,/hereby certify that the+tell(+) uas(irerr)constructed in accordance
+rich 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0 No copy of this record has been provided to the well owner.
tf this is a repair,fill out known+rell construction information and explain the nature of7lie
repair under a21 rentarks section or on the back of this Jornt. 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 supp/v+tells ONLY with the same construction,You call
submit one/orm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 27 (ft.) 24a. For All Wells: Submit this tbrm within 30 days of completion of well
For multiple+re//s list all depihs if'di#erent(example-3@200'and 2 a 100') construction to the following:
.. I
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater lerel is above casing,use"- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
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,Linderground 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 Erivironment and Natural Resources-Division of Water Res�i(ources Revised August 2013
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