GW1-2022-07486_Well Construction - GW1_20220810

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells j
1.Well Contractor Information:
14.Gary Ellingworth FROM ER ZONES ) I
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3367 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for m"Iti cased wells SS OR LINER ff a licable
FROM TO DIAMETER THICKNE MATERIAL
Parratt-Wolff, Inc. 0 ft- 12 fr• 6 i" 1 SCh40 I pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 15 ft. 2 'n' 1 SCh40 PVC
List all applicable hell permits(i.e.County,State,Variance,hirection,etc.)
ft. I ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 f`. 20 ft- 2 in., 010 SCh40 pVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. fn•'
❑Industrial/Comm ere ial ❑Residential Water Supply(shared) 1S.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 fL 12 ff• Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recover ft- 11 ft- Portland Cem Tremie
Injection Well: 11 ft, 13 ft- Bentonite Chil Tremie
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licible
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
13 fr• 20 ft. #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
a. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attaebaddifional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type.grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 7-21-22 s)Completed: Well ID# MW-139 ft. ft.
ft. ft.
5a.Well Location: ft. ft.
Central Park Burlington LLC ft. ft. IJIG _ 0 2022
Facility/Owner Name Facility ID4(ifapplicable) ft. ft.
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1708 10, Hilton Road Burlington fPffi3ilfSn
it. ft. D4"Q1800
Physical Address,City,and Zip 21.REMARKS
Alamance 139443 8"FMC
County Parcel Identification No.(PIN) 2�Concrete
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one lat/long is sufficient)
36.098354 N -79.410708 W a. a a
Signatur- e of ified We])Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By si_ ing onn, I herebv certi%v that the well(c)viav(here)constructed in accordance
With l SA NCAC 02C.0100 or 15A NC'AC 01C.0200 Well Construction Srandardv and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy ofthis record has been provided to the well owner.
I f this is a repair,Jill out known well construction information and explain the nature oJ'7he
repair under.21 rennorkv.section or on the hack gf7hisJorm. 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-crater supply o•e/dv ONLY wish the.same construction,you can
.smbmir one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple well,list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below tap of casing: Unknown (ft) Division of Water Resources,Information Processing Unit,
#water lerel is abore casing,use- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Injection Wells ONLV:I In addition to sending the form to the address in
24aabove. also submit a copy of this form within 30 days of completion of well
4 1/4 HSA,2"split spoons;8 1/4 HSA,6"pvc,6"Air Rotary
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:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: we11 construction to the county health department of the county where
constructed.
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Form GW-I North Carolina Department of Environnient and Natural Resources-Division of Water Resources Revised August 201?