GW1-2022-07489_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
I.Well Contractor Information: '
Gary Ellingworth 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name Q ft. ft. J-
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. ft. in.
Company Name• 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 4 ft- 2 in. sch40 PVC
List all applicable well permits(i.e.County,Stare,Variance.Injection,etc.)
fr. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 4 ft- 14 ft- 2 in. .010 sch40 PVC
fr• ft. in.❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)❑industrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑irrigation 0 ft. 1 ft- Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovers•
1 ft- 2 fr. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 ft-
0 14 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) ft. ft.
4:Date Well 7-18-22 MW-138 ft. ft.
Completed: Well ID# fr. ft.
5a.Well Location: 0
ft. fr.
Khalid Sayyed Shahid Ali ft. ft. AI -
Facility/Owner Name Facility ID#(if applicable) fr. ft.
301 North Cobb, Burlington ft. ft. , f1"z �Un4
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Physical Address,City,and Zip 21.REMARKS
Alamance 139479 's°FMC
County Parcel Identification No.(PIN) 2'Concrete Pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/lone is sufficient)
36.099512 N -79.411204 W It
Signature o'Certitied ell Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing t tis_Jbrnu I hereby certify that the we//(s)was/here)constructed in accordance
With I5A NC'AC 02C.0/00 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ZlNo copy ajthis record has been prorided to the well owner.
lflhis is a repair,fill out known well construction h?1brntation and explain the nature ojtte
repair under .21 remarks.section or on the hack gjrhi.s 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: 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,Jbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 14 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths'fdifferem(example-3 200'and 2@/00') construction to the following:
10.Static water level below top of casing: 9 (ft.) Division of Water Resources,Information Processing Unit,
/J water level is above casing,use"-" 1617 Mail Service Cienter,Raleigh,NC 27699-1617
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11.Borehole diameter: 2 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
4 1/4 HSA 2" split spoons 24a above. also submit a copy ofl 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
consuucted.
Form GW-I North Carolina Department of Environment and Natival Resources-Division of Water Resources Revised.August 2013
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