GW1--06954_Well Construction - GW1_20231027

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Scott M.Werley 14.WATER ZONES
Well Contractor Name FROM ro DESCRIPTION
4.6 ft. 6.0 ft• s-ar sey sara
3344-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
ECS Southeast, LLP FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
W MO 5 0158 5 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. It. in.
Water Supply Well: 17.SCREEN
FROM '1'0 DIMIETER SLOT SIZE THICKNESS MATERIAI.
Agricultural °Municipal/Public o ft. 5 0 ft. 2 in. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOLNT
Non-Water Supply Well: ft. ft.
x Monitoring °Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge °Groundwater Remediation ,
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT Mt:TIIOD
Aquifer Test °Stomlwater Drainage o ft. 5 ft, #2 silica sand pour
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soiVrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks)
0 ft. 2.0 ft• light brown silty clay
4.Date Well(s)Completed: 10/6/2023 Well mot TW-3 2.0 ft. 4.0 ft. orange and white clay
5a.Well Location: 4.0 ft' 5.0 ft.
gray silly sand
IBM N/A ft. ft. - .z --
Facility/Owner Name Facility ID#(if applicable) ft. ft. ��'Q 4 r Al 5�L.
4205 South Miami Blvd, Durham, 27703 ft. ft.
Physical Address,City,and Zip
ft. ft. OCT 2 7 2023
Durham 157755& 157802 21.REMARKS h+`;;,w ; ;) . .•::-,.g 120
0._,;
County Parcel Identification No.(PIN) �' `"'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat'lone is sufficient) 22.Certifi lion:
35.899211 N -78.845752 10/19/2023
6.Is(are)the well(s)0Permanent or X°Temporar}' Signature of Certified Well ntrac r Date
By signing this form,i hereby certify that the scents)was(were)constructed in accordance
ordane'e
7.is this a repair to an existing well: °Yes or ©No with/5A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction information and explain the nature of the copy of this 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-I 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: 5'0 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:4'6 (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: 3.25 (in.) 24b.For Inflection Wells: In addition to sending the form to the address in 24a
hand 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&Injection 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 G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016