GW1-2022-07542_Well Construction - GW1_20220815

F
WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
I
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name ft. ft.
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
FROM TO DIAMETER I THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft- 2 in. SCh40 pvc
List all applicable well permits(i.e.Couniv,State, Variance,/njeclion,etc.)
in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER 1 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 tt. 20 ft. 2 1O'li .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) f. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 6 ft. Portland Cem Tremie
Non-Water Supply Well:
0 Monitoring ❑Recovery
6 ft. 8 ft. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK ifs livable'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 8 rt. 20 fr. #2 Silica Sand Tremie
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets.if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVmck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
6-28-22 MW-28 `L ft. 1'
4.Date Well(s)Completed: Well ID# s
ft. ft. IV L
5a.Well Location: ft. ft.
Orange County ft. ft. -
i
Facility/Owner Name Facility IDit(ifapplicable) ft. ft. l Pf 3Fs8n7t�
195 Torain Street, Hillsborough 27278 ft. ft.
Physical Address,City,and Zip
21.REMARKS
Orange 9865735223 2 x 2 Concrete Pad
County Parcel Identification No.(PIN) No Protective Casing
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field.one[at/long is sufficient) '
36.097853 N -79.109952 w. (�
Signature ofCertt to ell Contractor Date
6.Is(are)the well(s): 17Permanent or ❑Temporary By signing this form, I hereby certi/i'that she well(s)eras(were)constructed in accordance
With 15A NCAC 02C.0100 or 1 JA NCAC 62C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
I/'this is a repair,till out known well construction inlurmation and explain the nature g1'dne
repair under:=21 remarks section or on the back oJ'lhisJimm. 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 oneJorm. 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
Tor multiple wells list all depths ijdijjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
I/'waier level is above casing use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Iniection Wells ONLY: In',addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: HSA 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 m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) 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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013