GW1-2021-04188_Well Construction - GW1_20210401

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES ,�: ' 14.WATER ZONES
p.,o�' FROM TO DESCRIPTION
Well Contractor Name @ "a ft. ft.
A - 4121 AN x 1 Z�21 ft. ft.
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION rc?�S1Ct� IS.OUTER CASING for multi-cased wells OR LINER ifa licable
4:n 1 �`' FROM TO DIAMETER THICKNESS MATERIAL
- "y i 0.0 ft. 75.0 ft.
6.0 in 188 GALVANIZED
Company Name
SEE ATTACHED ORANGE COUNTY PERMIT 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#• FROM TO I DIAMETER I THICKNESS MATERIAL
list all applicable yell constrtiction permits(i.e.1/1C,Coumv,State,Variance,etc.) 0.0 ft- 98.0 It. 2.0 in. SCH 40 PVC
3,Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 98.0 ft. 103.0 ft' 2.0 in- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. fr. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 74.0 f[. PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery 0.0 ft. 75.0 ft. PORTLAND BENTONITE SLURRY
Injection Well:
fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK ifa' licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 90.0 ft. 103.0 it. 20-40 FINE SILICA SAND
❑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,sou/rock type,grain size,etc.
0.0 rt• 6.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 03/09/21 Well ID# MW-1 D2 6.0 ft. 11.0 ft- BROWN SILTY CLAYEY SAND
5a.Well Location: 11.0 fL 14.0 ft- PWR
CARR MILL MALL 14.0 rt• 16.0 rt• FRACTURED ROCK
Facility/Owner Name Facility IDk(if applicable) 16.0 rt' 103.0 rt. ROCK
200 NORTH GREENSBORO STREET CARRBORO 27510 et. a•
Physical Address,City,and Zip ft. ft. '
ORANGE 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL-74.0-90.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Certification:
35o 54' 41.47" N, 790 04' 13.24" W 03/10/21
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this Joan,l hereby certify that the tee/l(s)was(here)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or l!5No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Siandaretv and that a copy
1f ills is a repair,fill out known well construction iglbrmation and explain the nature o_jthe_ _ of this record has been provided to the ire//owner.
repair under=21 remarks section of 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 construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 103.0 (ft l
I?u nwhiple ire/tv list all depths ifa`VJereni(example-3@200'and 1 r(7i l00') Submit this GW-1 within 30 days of,well completion per the following:
96.45 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if hater level is above casing,use
12.0/6.0/10.0 24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
l 1.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/AIR
24c.For Water Supply and Open-Loon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push.etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
,
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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Orange County Health Department
Environmental Health Division
131;West Margaret Lane
(919)245-23601 Suite 100
[phone](FAX) ORANGE COUNTY P.O.Box 8181
www.orangecountync.gov NORTH CAROLINA Hillsborough,NC 27278
MONITORING WELL PERMIT
Parcel Number: 9778868789 Property Description: N/E INT WEAVER&GREENSBORO STS CARRBC
Application Date:02/25/2021 Property Address: 200 N GREENSBORO ST
Permit Number:W21-0044 CARRBORO,NC 27510
Applicant: ECS SOUTHEAST LLP Owner:
Address:4811 KOGER BLVD Address: PO BOX 673 4
GREENSBORO,NC 27407 CARRBORO,NC 27510
Phone: [phone] Phone: [phone]
Email: [e-mail] Email: [e-mail]
Well Type: Other Lot Size:-8.32
Well Class: New Sewage Disposal: Sewer System
Comments/Conditions:
Condition Description Comment
General Permit for monitoring well
ISSUED: 03/01/2021 ' EXPIRES: 03/01/2026
Kathryn Hobby
ENVIRONMENTAL HEALTH SPECIALIST
•The permitee is responsible for obtaining all required permits,and/or approvals from other agencies(i.e.:Zoning,Inspections,State)
•Refer to the attached site plan showing the well and facility locations and any other specifications.Any changes to the proposed plans must
be approved by the OCHD.
•Wells must be constructed,repaired,and abandoned by a person who holds a valid certification from the State and who is also registered in
Orange County for well construction.A list of registered well drillers is available upon request.
Well contractor must call for casing grouting inspection and for inspection of completed well including permanent markers.
ID TAGS ARE REQUIRED ON EACH WELL TO SHOW:
(1) well contractor name and certification number;
(2) date well completed;
(3) total depth of well;
(4) a warning that the well is not for water supply and that the groundwater may contain hazardous materials;
(5) depth(s)to the top(s)and bottom(s)of the screen(s);and
(6) the well identification number or name assigned by the well owner.
'The owner is responsible for marking all property lines and comers.The Contractor is responsible for ensuring that the wells are installed in
the proper location and that all setbacks are met.
THIS PERMIT MAY BECOME INVALID AND MAY BE REVOKED IF:
•The information submitted on the application is incorrect,falsified or changes,
`The site is altered,or
•The well is not completed before the expiration date.
THE WELL SHALL BE CONSTRUCTED OR REPAIRED IN ACCORDANCE WITH:
Orange County Groundwater Protection Rules as adopted by the Orange County Board of Health.
NC Well Construction Standards,as applicable and
Orange County Environmental Health Division Policies.
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rpt PM_Oc_EH_WellPe—it 2021.3
Report created:3/1/2021 1:34:16PM
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