GW1-2022-08522_Well Construction - GW1_20220519

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 19 ft. 25 ft. wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LER if a licable
FROM TO DIAM1fETER THiCKINNE55 DiATER1AL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 f" 5 ft. 2 in. sch40 pvc
List all applicable hell permits(i.e.County,Slate,Variance,h jection,etc.)
ft. f[. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 25 ft. 2 in. .010 sch40 pvc
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) ft. f. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 1 ft. Portland Cem Tremie
Non-Water Supply Well:
1 ft. g fr. gentonite Chi Tremie
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3 ft• 25 #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) El Other(explain under 421 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 5-6-22 Well ID#TW-5
ft. ft.
5a.Well Location: ft. ft. r �^.r^P• 5 e
Barbara Jackson/Kelly Stephen George ft. ft. - -
Facility/Owner Name Facility iD4(if applicable) ft. ft. MAY 1 2027
5052 Wake Forest Hwy, Durham ft. ft.
Physical Address,City,and Zip
21.REMARKS
Durham 0861-00-34-5914 2 x 2
County Parcel identification No.(PIN)
4"Pro Cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
35.976361 N -78.796401 W
Signature of Certified Well Contractor �� Date
6.is(are)the well(s): ©Permanent or ❑Temporary By signing lhis form,1 hereby cerlify that lire ivell(s)was(here)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 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 file hell owner.
If this is a repair,fill out knoirn well constriction information and explain the nature of the
repair under=21 remarks section or on the back oJ'lhisJorm. 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 nmlliple injection or non-water supply wells ONLY with the Nance construction,you can
submil one form. SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For imi/tip/e we/Is list all depihs ifdiffereni(example-3@200'and 2 cr 100') construction to the following:
10.Static water level below top of casing: 19 Division of Water Resources,Information Processing Unit,
Ifwarer level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
4 1/4 HSA 4"Air Hammer 24aabove, also submit a copy of this form vithin 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gP ) 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