WI0501131_Well Construction Record(s) (GW-1)_20240514

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
RECEIVED
1.Well Contractor Information:
14.WATER ZONES
Joshua N. Robertson MAY 1 4-2024 FROM TO DESCRIPTION
Well Contractor Name ft ft 127GPM@1-10'
2461-A NC DEQ/DWR ft ft
NC Well Contractor Certification Number Central Office 15.OUTERCA TOSING formulticasedwd➢s OR LINER ifa licable
FROM DIAMETER THICKNESS MATERIAL
Triad Drillers, Inc. 0 & ft
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
w24-0007 FROM TO DIAMETERrs
THICKNESS MATFRr
2.Well Construction Permit M ft ft UL
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MA'ERLAL
ft ft in.
❑Agricultural ❑Mumcipal/Public
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft in
❑Industrial/Commereial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 26U_ ft- Thermal Pump
Non-Water Supply Well:
ft ft Grout
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if 'able
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft To ft MATERIAL EMPLACEMENTMEMOD
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20,DRILLLti4-LOG tattaeb additional sheets if now
❑Geothermal(Closed Loop) ❑Tracer IROM To MCRUMOx color.bardne soiltmek tyM grain airs,etc
❑Geothermal(Neatin Coolin Return) ❑Other(explain under#21 Remarks) 0 ft 1-5 ft Clay
5/7/24 9851122928 1-5 ft 260- ft Granite
4.Date Well(s)Completed: Well ID# & ft
5a.Well Location: ft ft
Kathy Hawkins Campbell ft ft.
Facility/Owner Name Facility ID#(if applicable) ft ft
6301 Dodson Crossroads ft ft
Physical Address,City,and Zip Il.REMARKS
Orange
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer'ication-
(ifwell field,one lat/long is sufficient)
N W 5/10/24
Signature Certified Well Contractor Date
6.is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 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 ®No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 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: 6 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 4@260 2@300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2 a@100) construction to the following:
10.Static water level below top of easing: 80 (fti) Division of Water Resources,Information Processing Unit;
Ifwaier level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 27699-16M
139.Yield m) 0-10 Method of test: Air 24c.For Water Supply&Injection Wells:
(gP Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: 16 oz. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013