_Well Construction - GW1_20230327 (26)

SWELL.CONSTRUCTION RECORD
For Internal tlscpNLY:
-- This form cut be ttscil COT single or multiple wells l /'
%%
L .Contractor Information: \
<\�� :`1 .w.a:FEREDNES . •
Stefan Smith \ tows]. to DESCRIPTION
wen ContractorN:trna ft. ft.
3576-A ft, ft
NC Well Cormae tor certification Narita: 15.MUTER CASiNG(for iiirittt-crve8lselisiOR LINER'(if nn itka6kl+. - .
FROM 1 m . DIAMETER TRICIOIESS MATERIAL.
SAEDACCO Inc 0 ft. 17 fL 2" , In. SCH-40 PVC
ComputyNantc 16:INNER.CASiNGORTt2®ING:4 riaiherttt:trrtnki1-bill% - _.
FROM TO • DIAMETER TUICrKNESS MATERiAL
2.Wdt Construction Permit#: ft, ft.• '
Pdn ort gtp2fci:Pik IMP}trrmLts(i_e.Cnuiuv,Shoe,t'iir(air ,Inject*e1s7 i .
3.Wsll lisp(cheel:wdl trsc): .
17:SCREEN
Water Supply Well:• -, 11W'I It) altstsTI:R SLOT SUE 'IMICNNrss I \L%TERtAl.
InAgticulttttal ElMtiuicipahrublic 7 It. 17 ft. 2" 010 SCH-40 PVC
l�Geothemlal tllcatinglCoolingStipply) llResidential•Water Supply(single) It. It: it!,
IIIttdustriaL'Coutnten ial DResideutnd W'stee Supply(sh red) ttt•
GROUT . _...,-.c
FROM • •TO. • MATERIAL C'MPLACEMEIT.NirnionRANIOt1NT
❑/cripation • . . 0 ft- 3 fL Portland Pour
Nqu-Wa ter Supply WPM ft. tl: .
5d11'lonitoring flt canary _ ,
injection Well: ft, ft.
CI%quifcr Recharge . . AGroutidil ticr Reniediation •19::S ND;(.RAVLL PACk(il applteatcl' ._ - :- - --
'FROM •7I} - dfAttur..i •R\INLACEMENTMITgOn •
❑Agtiifcr:Stotagc and Recovery I:Salinity Barrier 5 R. 17 ft. FILTER SAND #2
. ❑AgnifcrTest ❑Slorrrw tcrl}n(inagc .(t. ft,
❑etpertnicntal Technology • IJSuhsidencc.C_ontrol ,
,20.DRILLING LOG'iallacli addilionalSlicers'if neeessnrti'l• • •
DGetltznnal(ClosedLuup} LITracer FROM• - TO - DESCRIPTION tcntanbaronies,statoic4ivtx.vatic*ism.cle.l
❑Geotltentiat 1IeatinuCoolitlgReturn! ❑Outer(explain underi2I Retuaties) .ft., ft,
-It.. fL
4.Date.Well(s)Completed: 3/1/23 Well iD#MW-5
ft. it
5a.%►tell1.11cation: fL ft, tt`` -r 21„-
? i' s_ s
Former White Star Laundry ft.- ft,
Facitity,tlivi cr.Nmnc • Facility IDk(9Eapph.able), R ft. MAR-2-72023
610 Lakeland St., Durham, NC, 27701' ' It. it, s
• Pltysical.Addicss.City-anitZip ,21 REMARKS ' •. •• a+:. " ,. .:�.ll:;: •
Durham
Bentonite seal from 3-5-' �" f�
Conuty Patrc]Id;uilitteatloir No.(PIN)
51i,Latitude'and I,ougitittle in(legrccs/minutcslscconds nr dccimul degrees: 22,Certiticatirtn:
Orwell tt 1r1,pta IuU7istia ig tcilicictil) c� p
N �V -✓ ,,..i�.?:'�"`t'iUzj/ _ 3/16/2023
Sieait Ce.lied Well Contactor Datc
6.is Ore)the"well(s): 27Permanent or ❑Temporary 6r xgsting this fgim,.I hereby cerlifv char the well(.0 rsrtr(µmil anz.?.1nrcierl Itr aceorehrnce
with 15 t NC4C 02C,0100 or 151 NCCtC 02C:41201)11 Well Conatrr crinn Sr.:Ma s crrtd Ow a
7.Ls this a repair-tie a>i ctistigptivelli i7Vui or t;IN0 c'rijn ofthic teethe hrts'hem 1.;;raided rr.'i'he%veil mr,irv,
if rhts:I.a%%)only./IIN ow keens*ell con nuelloo informal-On mill(..ipkrhi the ware of the
repair ratrlet 021 rivncrla siLl'tiun or vn the back:of that forme. 23:Site diagram or additional well details:
You may use the back of this page ii proc'ide addiiioual well site,details:or Welt
S.Number of wells constructed: 1 construction details. You Mac alsti-attach additional pages if iiecess ny.
For ritttlriple Irfeerlwt or oon-rrnrer supply wells ONLY MIA Thtt.stntte eturstriiiliwt,you cant
sth,nitone fprm. .SUBMITTAL INSTUCTIONS
9.Total Well depth betoir land airfare: 17 (ft.). 24a..For Alt Wells: Submit this fonn within 3u days of cdmptefion'of welt
For nruhiple''wells list all depths if dlf reitr ieraa,plc-.;64':00'atut.:@ 100 con5tnictien to Ilia Mooing: •
W.Static:water le'.el below top of easing: . (ft) Dil'isiun of Water Resources,lnformgtipn Piucessing Unit,
'limo:et Iei'el is above&stag,ime"+" 1617 Mafl.Seri•iec Center,Raleigh,NC 27699-1617 '
11„Borehole diameter 4" - . (in.) 24b.For ftntiglllstn{Wills ONLY: In addition to'sending the fomrto the address in
24aabove, also submit a copy of this faint within 30 days of cou]pletiou of well.
12.Well consttvetion method:Air Rotary cot:stmcliott to the followine:•
(i.e.aura_rofaly.cable,'direct posh etci( .
. . Division of Wiater.Reyourccs,Undetgrouied Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center,Raleigh.NC 27699-1636
i
c3a,•Vicld( fm) • ltictltod of test: 24e.For Water Su uplr St.[ejection Wells:. •
Also submit one copy of this faint within 0.day of completion of
13h.Disinfection ty die: Amount well constmetion to the county health''department of the coimly where
constnuted.
I
Form GW-L tlonit Carolina Department of Eneltatui}_tn and Natural Resources-Division of Water Re'atres Revised August 2.013
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