GW1-2023-00776_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information: li
DAVID HALL 44.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4459 4
rr. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wills OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. I ft. I in.
Company Name
16.INNER CASING OR TUl31NG eofhermal closed-loop),
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable uvell construction permits(i.e.VIC,County State,Variance,etc.) 0.0 ft- 5.0 ft- 2.0 '"' SCH 40 PVC
3.Well Use(check well use): ft. ft. is
Water Supply 17.SCREEN
PP y Well: FROM TO DIAMETER'S SLOT SIZE .THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 5.0 It- 15.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL! EMPLACEMENT METHOD&AhfOUNT
Non-Water Supply Well: 0.0 ft- 3.0 ft- PORTLANDBENTONITE SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well:
fr. a.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage 4.0 ft- 15.0 fL 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control fr. ft:
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soillmck type,grain size,etc.)
0.0 ft. 1.0 ft. CONCRETE
4.Date Well(s)Completed: 11/22/22 Well ID# MW-g 1.0 ft- 15.0 ft- CLAY
5a.Well Location:
CIRCLE K - 2723780 f`' f` 1 EAU L + 202
Facility/Owner Name Facility ID#(ifapplicable) fr. ft. - ^M ^
3321 NC - 55 DURHAM 27133
Physical Address,City,and Zip ft. ft.
DURHAM -21;REMARKS,, -• . '
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 55' 56.39" N 780 53' 15.78" W ��� ��/ 12/01/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,1 hereby certify ilia!the Irell(s)was(were)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
f/Yhis is a repair,fill out known uvell construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells(laving the same You may use the back of this page to provide additional well construction info.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15.0 (ft.) '
For multiple bells list all depths ifdiereni(example-3@200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
7.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
/f water level is above casing,use"+
f Static water level below top of casing: (ft.) Information Processing Unit,161YMSC,Raleigh,NC 27699-1617
"
11.Borehole diameter: 8.0 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER f
24c.For Water Supply and Open-Loon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pushy etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(-.pm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
,
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018