GW1-2023-02798_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
David Scott Tignor IC WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
17.7 ft 53 ft. wa er Co umn
4024-A
ft. it.
NC Well Contractor Certification Number 15.OUTER CASING for mi Ii-cased wells OR LINER if a livable)
Froehling & Robertson Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0.0 ft. 43 ft. 2 "' I Sch 40 PVC
16.INNER CASING OR., ING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DLIMETER I THICKNESS MATERIAL.
List all applicable well construction permits ri.e. UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 43 ft 53 ft. 2 in. .010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 40 fL Neat Cement Trimmle
X Monitoring ❑Recovery 40 ft. 42 ft. gentonite Gravity
Injection Well:
ft, it.
[]Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 42 ft. 53 ft, #2 Well Gravel Gravity
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUrock a to s' etc.
)ft. ft.
4.Date Well(s)Completed:3-15-2023 Well ID#B-9 ft. ft. -
C
Sa.Well Location: . ft. ft ..«._
NIEHS ft. ft. APR 1 % 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
111 TW Alexander Dr. Durham, NC 27713 fL ft. „ ;, ,;,,.7 77
Physical Address,City,and Zip ft. fL
Durham 21.REMARKS
County Parcel Identification No.(P"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 22.Certification'
35.8859163 N -78.8757376 W n
4-11-2023
6.Is(are)the well(s) IX Permanent or ❑Temporary Signature of Certified Well C ntractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or ]No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy of this 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 having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 53 (10 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below to of casing: 17.7
p g� (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: 8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Auger above, also submit one 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,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&Iniection Wells: In addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 2-22-2016