GW1-2022-07543_Well Construction - GW1_20220815

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO 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 6cable
FROM TO DIAMETER ! THICKNESS MATERIAL
Parratt-Wolff, Inc. fr. ft.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER 4. THICKNESS MATERIAL
2.Well Construction Permit#: 0 fr. 8 ft. 2 in. sch40 PVC
List all applicable well permits(i.e.C outnv.State,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 18 "- 23 ft- 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 4 ft- Portland Cem Tremie
Non-Water Supply Well:
RlMonitoring ❑Recoven' 4 ft- 6 ft. Bentonit Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licatile
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
6 ft• 23 ft• #2 Silica 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 sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. e
6-24-22 MW-25 ft. ft. �° `' -
4.Date Well(s)Completed: Well ID# fr. ft. y
5a.Well Location: ft. ft.
Orange County ft. ft. Ufa
If1jC�A-tom-'1 Prc:+". 9
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
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)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(ifwell field.one[at/long is sufficient) I -
36.092091 N -79.110767 w ��
Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent Or ❑Temporary By signing this orm, 1 hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.01 C/0 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Y-es or ElNo cony gl'this record has been prorided to dte',,re/l owner.
4 this is a repair,fill out known well construction information and explain the nature of the
repair under=21 remarks section or on the back gf this jbrm. 23.Site diagram or additional well details:
You may use the back of this page to'provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Far multiple injection or non-traler.supply tre/ls ON1.Y with the same construction,you can '
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 23 24a. For All Wells: Submit this form within 30 days of completion of well
Far inuhiple wells list all depths ifdifferent(example-3@200'and 2@1C10') construction to the following:
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10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water lerel is above casing,use--" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: Inl 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.) f
Division of Water Resources,Llnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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m 13a.Yield
(gp ) Method of test: 24c.For Water Supply&Injection Wells:
,
Also submit one copy of this form within 30 days ofcompletion 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 Resolurces Revised August 2013