GW1-2022-07488_Well Construction - GW1_20220810

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
s ,
GaryEllinryryWOrth 14.WATERZONES
y FROM TO DESCRIPTION
Well Contractor Name
3367
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft, fr. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 3 8 ft. 2 '" SCh40 PVC
List all applicable weN pernuts(i.e.C'ountr,Stoic, Variance,Injection,etc.) ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3.8 ft' 13.8 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. .5 ft- Portland Cem Tremie
Non-Water Supply Well:
5 ft. 1,5 ft• Bentonite Chi Tremie
RlMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
1.5 ft' 13.8 ft' #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
4.Date Well 7-18-22 MW-137 ft. ft.
$)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Northside Presbyterian Church ft. ft. y
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. J
Burlington ft. ft.
IrIFo'¢ on Prtxwasarls Ursa
Physical Address,City,and Zip 21.REMARKS
Alamance 139783
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
36.100211 N -79.407505 W �-
Signature of ns ','rin,
fied Well Con actor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing d 1 hereby certi/p that the ire/l(s)was(here)constructed in accordance
with 15A NC'AC 02C.010C1 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑l es or E]No copy of this record has been provided to the we//corner.
!'this is a repair,Jill out known well construction information and explain the nature q'the i
repair under=21 remarks section or on the back q/'this/brm. 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-water supply wells ONLY with the same construction,you can
.submit one forni. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 13•8 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i'dtf'erent(example-3 a 200'and 2@100') construction t0 the following:
10.Static water level below top of casing: 13 (ft.) Division of Water Resources,Information Processing Unit,
1/'water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY:1 In addition to sending the form to the address in
4 1/4 HSA 2" split spoons 24aabove.. also submit a 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:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
r
Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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