GW1-2022-09708_Well Construction - GW1_20220519

i
Field.IQ #
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells -
1.Well Contractor Information:
Kevin White 14.NVATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 13 fit• 25 ft. wet
2973 fit. fir.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LiNER if a licable
FROM TO DIAMETER THICKNESS TATERIAL
Parratt-Wolff, Inc. fit. ft. I in,
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 24 ft. 2 in. sch40 PVC
List all applicable well permits(i.e.Comuv,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 24 ft- 35 ft- 2 in. .010 sch40 PVC
❑Geothermal ) ❑Residential Water Su (single) ft. ft. in.
(Heating/Cooling Su PPIY PPIY
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irigation 0 fit 20 f` Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 20 ft. 22 ft- Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 22 fit• 34 ft- #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional streets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soff(mck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 5-5-22 Well ID#TW-4A
ft. ft.
Sa.Well Location: ft. ft.
Barbara Jackson/Kelly Stephen George ft. fir.
r
Facility/Owner Name Facility[Df!(if applicable)
5052 Wake Forest Hwy, Durham
ft. ft.
4
Physical Address,City,and Zip
21.REMARKS
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)
35.976020 N -78.795785 W V'.Q_ ,_
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or []Temporary By signing this Jimni,I hereby cerlt&that lite ire//(s)was(were)constructed iu accordance
with 1511 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy oJ7his record has been provided to the we//owner.
If this is a repair,Jill an known irell construction in%rmation and explain the nature of the
repair under`21 remarks section or on the back q('this 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 nnihiple byeclion or non-crater supply hells ONLY with the saine construction,you can
subinit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 34 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple use//s list all depths iJ'different(example-J a 200'and 2@100') construction to the following:
10.Static water level below top of casing: 13 (ft.) Division of Water Resources,Information Processing Unit,
ifirater lerel is above casing,use••-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b.For Iniection 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 following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Linderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.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 Environnient and Natural Resources-Division of Water Resources Revised August 2013