GW1-2021-03634_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells {
1.Well Contractor Information: "
FROM TO DESCRIPTION
Chauncey Leggett It. ft
Well Contractor Name ft ft
i
2269-A 15OiJTERASINGormulhlcased wells}FOR THE (tfappLcalil")� ''
NC Well Contractor Certification Number FROM A TO DIAMETER THICKNESS MATERIAL
ft ft in.
Lake Valley Well Co.,Inc
Company Name M ft. in.
16'aNI ER GASING'OR°`TUBI] G(gco t'enn closed loop)';
..
2.Well Construction Permit#: FROM TO DIAMETER THICKNESI MATERIAL
List all applicable well construction pertmits ft County,State, Variance,etc. ft ft in.
3.Well Use: ft ft in.
liT�SCREEN
FROM c TO DIAMETER I TWCKNESJ SLOT S# MATERIAL
Residential ft ft. in.
ft ft in.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Grouting Through
ft. ft
ft ft
19kSANDlGRe1�'E AGW(tfapplictib,e};
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
4 ft 285 ft xtra Fine Sand 30 Tremie Pipe
ft ft
4. Date Well(s)Completed: 5/6/2021 Well ID# Geothermal ft ft
Sa. Well Location: 20:l)RIIZINGbLOG' attach a c7honal sheets jf oecessar
y) ..
List all applicable well construction pertmus ft County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Bowman Mechanical Services Inc. 0 ft 19 ft Brown Clay&Boulders
Facility/Owner Name Facility ID(if applicable) 19 ft 220 ft Gray Granite
1019 Demerius ST Durham 27701 Lot 220 ft 285 ft Purple Granite
Physical Address,City,and Zip ft ft
Durham 0822-63-63-2535 ft ft
County Parcel Identification No.(PIN) ft ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft
(If well field,one lasufficient.)long is sufficient.) 21 yREMA°RICSr' ''. r + .. - �?~ k
36.011855 N -78.910107 W used 1 bag of Barotherm to'3 1001b bags of extra fine sand
6. Is(are)the well(s): Permanent
22. Certification: G 1/,���(/(/
7. Is this a repair to an existing well: No Y� 5/6/2021
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well Contractor Date
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 3 copy of this record has been provided to the well owner.
For multiple injection or non-water wells ONLY with the same construction,you can 23. Site diagram or additional well details:
submit one form. You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 285 (ft)
For multiple wells list all depths if dierent(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
0.Static water level below top of casing: (ft)
construction to the following:
If water level is above casing,use"+" Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Infection Wells: In addtion to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): Method of test: Air 24c.For Water Supply Infection Wells: In addtion to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
13b. Disinfection type: HTH Amount: OZ completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised 2/22/I6