GW1-2022-08484_Well Construction - GW1_20220519

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 26 rt• 34 ft' wet
2973 ft. ft.
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. et. tr. in.
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
FROM I TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 24 tt. 2 in SCh40 pvc
List all applicable ire//permits(i.e.County,State,Variance,h jection,etc.)
ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 24 ft. 34 ft. 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) ft. I ft. tn.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 er. 20 ft- Portland Cem Tremie
Non-Water Supply Well:
20 ft. 22 et. gentonite Chi Tremie
❑+Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 22 ft- 34 tt• #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,gnuin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
5-5-22 TW-3 ft. ft.
4.Date Well(s)Completed: Well[D#
ft. ft.
F"'!4T"•.�r
5a.Well Location:
ft. ft.
Barbara Jackson/Kelly Stephen George
ft. ft.
Facility/Owner Name Facility lD4(ifapplicable) ft. ft.
5052 Wake Forest Hwy, Durham ft.
Er
Physical Address,City,and Zip 21.REMARKS Ys1 ^a ,c,.` s^
Durham 0861-00-34-5914
2x2Pad
County Parcel identification No.(PIN) 4"Pro Cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
35.976245 N -78.795425 w '�(��, �' ZZ
Signature ofCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this Jbnn,I hereby certify that the ire/l(s)iras(here)constructed in accordance
with 15A NCAC 01C.0100 or hA NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: []Yes or ONo copy ofthis record has been provided to the ire//owner.
/fthis is a repair,fill out known well construction information and explain the nature of'the
repair under 21 remarks section or on the back gl'ihis 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 h jection or non-eater supply ire//s'ONLY iNih the same construction,you can
SUBMITTAL INSTUCTIONS
submil one form.
9.Total well depth below land surface: 34 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ire/Ls list all depths iJ'dijferenl(example-3 a 100'and 1@100') construction t0 the following:
10.Static water level below top of casing: 26 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b.For Iniec6on Wells ONLY: In addition to sending the form to the address in
4 1/4 HSA 4" Air Hammer 24aabove, also submit a copy of this form vithin 30 days of completion of well
12.Well construction method: construction to the followins:
(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.
I
Forni GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013