GW1-2023-02797_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
David Scott Tignor 14.WATER ZONES,
Well Contractor Name FROM TO DESCRIPTION
4024-A 22.8 ft- 39.5 ft• we er ca umn
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased.weUs OR LINER if a licable)
Froehling.& Robertson Inc. FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft 29.5 ft- 2 m' Sch 40 PVC
Company Name
16.INNER CASING OR TUBING eother a]closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits Cz.e. UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
i7.SCREEN:.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 29.5 ft, 39.5 ft* 2 in. .010 3ch40 PVC
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑IIri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 26.5 ft• Neat Cement Trimmle
X Monitoring ORecovery 26.5 ft- 28.5 ft. Bentonite Gravity
Injection Well:
ft.. ft.
❑Aquifer Recharge ❑Groundwater Remediation
:49.SAND/GRAVEL`PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage 28.5 ft- 39.5 ft- #2 Well Gravel Gravity
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary),
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soWrock type,grain sire,etc
ft. ft.
4.Date Well(s)Completed:3-14-2023 Well ID#B-6 ft. ft.
5a.Well Location: ft ft
NIEHS ft. ft
Facility/Owner Name Facility ID#(if applicable) ft ft A rp R 1 7 2023
111 TW Alexander Dr. Durham, NC 27713 ft ft
Physical Address,City,and Zip ft ft
Durham 21.REMARKS
County Parcel Identification No.(PER)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.8859481 N -78.8761510 W
- 4-11-2023
6.Is(are)the well(s) IX permanent or. ❑Temporary Signatur enified Well C ctor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes orINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed: Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 39.5 ft.
P ( ) 24a.For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100� construction to the following:
10.Static water level below to of casing: 22.8
P g� (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Auger above, also submit one 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,Underground 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&Iniection Wells: In addition to sending the form to
the address(es) above, also submit• one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to'the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016