GW1-2022-08511_Well Construction - GW1_20220519

WELL CONSTRUCTION RECORD For Interval Use ONLY:
This lbrni can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 13 ft. 25 ft. wet
2973 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable
FRONT TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. I ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft. 2 1O SCh40 pvC
L&I all applicable well permits(i.e.Coun(v,Slate,Variance,ll jeclion,etc.)
f[. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 t' 25 ft- 2 in. .010 sch40 pvC
❑Geothermal(Heating/Cooling Cooling Supply) ❑Residential Water Su ly(single) tt. fr. in.
( PP
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 1 I Portland Cem Tremie
Non-Water Supply Well:
2Monitoring ❑Recovery 1 " 3 1Bentonite Chi Tremie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
3 ft' 25 f`• #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) El Other(explain under#21 Remarks) ft. ft.
4.Date Well 5-6-22 TW-4 ft. ft.
$)Completed: Well[D# ft. ft.
5a.Well Location: ft. ft. F z�' P !
Barbara Jackson/Kelly Stephen George
ft. ft. r)
Facility/Owner Name Facility lD4(if applicable) tt. ft.
5052 Wake Forest Hwy, Durham ft. ft.
ii
Physical Address,City,and Zip t
Y tY, P 21.REIIIARICS
Durham 0861-00-34-5914 2 x 2 Pad
County Parcel Identification No-(PIN)
4"Pro Cover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.976043 N -78.795951 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this Jornt,l hereby certify that the re//(s)was(mere)consinacled in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consiruction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy oJ'Ihis record has been provided to the well owner.
ljthis is a repair,Jil/oul known well consintction inforotalion and explain the nawre of'lhe
repair under--21 remarks section or an the back q1 ihisJorm. 23.Site diagram or additional well details:
You may use die 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-rater supply wells ON1.Y arith the sane construction,you can
submit one firm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 24a. For All Wells: Submit this form within 30 days of completion of well
Far nudliple wells list all depths tjdiJJerenl(example-3(a Inn'and 2@100') construction to the following:
10.Static water level below top of casing: 13 (ft-) Division of Water Resources,Information Processing Unit,
//hater/ere/is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b.For Injection 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 within 30 days of completion of well
12.Well construction method: construction to the followine:
(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
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 201',