GW1--04535_Well Construction - GW1_20230713

WELL CONSTRUCTION RECORD \k� Far intenai Use ONLY: •
This form cart ho used for single or multipk wells• `�
1.Well Contractor Information: \ - • -
'I.I.WATER ZONES
Zach Thompson I I1051 TO DESCR PCION
in. fi.
Well Cor'araaM NaPIO
4478A ft. ft. 1
NC WeI1 CantrsctorCcnifisatian NumberIS.OUTER CASING(roi'muhi-costa ells1 ORhLiNER ltf"ati flcjbk)
FROM TO DIAMETER THICKNESS MATERIAL
SAEDACCO Inc 0 ft. 18 fL 6 La SCH-40 ' PVC
Cmnp:uty Nana .16:INNER CASING OR TUB1NCigeoibermal closed-loop). •
FROM TO - DLLMETER THICKNESS • MATERIAL
2.Welt Construction Permit#: R. rt. Et'.
List all applicable WV 1lpenults fir.County.Maw,.Vnrinirce,ft)rcYb.rb ear.)
R. ft. nr.
3.Well Usc(cheek well use): 17.SCREEN
Water Supply We1L• FROM I Tat DIAMETER SI.OT•Sin: 1111(1?4F S I MATERIAL
. °Agricultural MinnicipaltPtblic ft. R. in,
❑Geothermal(Heating/Cooling Supply}. ❑Residential Water Supply(single) . ft. ft. in,
©Industrial/Conmtcrcial °Residential Water Supply(slated) Fro R-UT 1.6. MATERIAL EtiPLAC1 IIEVT N 2T11On S AMOUNT
❑Irrigation 0 ft. 18 fL Portland Injection
No Supply Weil:
❑Monitoring .fRecovery ft. ti
Injection Welt: rt. fL
°AquiferReCharge ISIGionndmttcr Roucdiaticrn •L9 SANDJGRAVEL PACE{(ifa)r)ilicabte)'•
FROM • TO • MATM1tLSt. RUPI.ACEMIENT M ETufln
❑Atlnifer Storage and Recovery ❑Salinity Dar ice n. fi
❑Agil ferTest ❑StommatcrDrsinagc .
•R. ft.
❑l xperimcntal Tcchnolou ❑Sltbsidcncc Control.
20.DRILLING'LOG(attach additional sheets if ncccstart)
❑Geother mtl(Closed Loap) ❑Tracer .FROM TO DESCRIPTION fi Ibr.hadneo.wt:n>ekhtx.rrs+n Nra.de.)
❑Ge titennal(11-earing'Coolino Return) ®Other(explain under#21 Rewaibs) 0 fL 18 fL. Brown/Tan silt
18 ft. 31 ft. Rock
4.DateWetl(s)Completed: 6/15/2023 Well IDNIW-19
ft. fL
ia.Well Lttcatimm ft. iL t .' R ..,
GSR It. ft.
Facilit},OtvncrNant Facility LDk(ifappliatble) R. ft. - JIt yy r--
3175 Genesis Way Durham, NC, 27703 r __
R. fL Irma r.r,a'.i rC :;74F,g 1:f7i
Physical Address.City.and Zip :21.REMARGS Cjt; ; `.)'=
Durham Open borehole from 18-30'
Comity ity Parcel Identification No;(PIN)
Sh,Iaapitude'and Longitude in dcgireslminutcs/sceonds or dcei►nal degrees: 22.Certification:
• (foell fold,Orr 1a51otig in sullielaia)
35.9182 . N -78.8642 w 5li 714)0/.JC'e-e. P • 6/21/2023
mature of Ccitificd Well tontmetor Date
6.Is(are)the\a'ell(s): xlPCru►anenl or ❑Temporal}' !Ir.signing this fame,1 hereby certify that the n•ellfs1 was(warn)cvnrrnrcted in accordance
with 114 NCAC 02C.(lift)or 154 NCAC 02C.13200 Well Cots/ruction Sranlards and that a
7.Ls this a repair to an existing well! DYe.s or EN° ropy of thisrerondhasNren pore i ki(ratbe aril mrncr,
I/this it n repair,fill oar kronor well c onsua(e:loa brfor:rnnkvt Oral explain the,Iarrue of the
repair wider$21 remarks srciimr or m the bark of 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 cousttuctiui►details. You may also attach additional pages if necessary. •
For,mrlalple Iafeealnn or nor'-wee snpplr;veils ONLY with the same co,rstriwlion,yi+n can
saimtironeform. 'SUBMITALiNSTI.LCTIONS
9.Total well depth below land surface: 30 ((t,) 2.1a Nor All Wells. Submit this fans within 30 days of completion of well
For teahlpio wells list nil depths ffdlfferent(example-.i m200'and 2e,100) consinictic o to the fallnningg: ,
I0.Static water level below tap of casing: • (ft.) Division of Water Resources,Information Processing Unit,
If water level Is above cask",ass'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
Ill.Borehole diameter:4" (in.) 2.1b.Far infection Wells ONLY: In addition to sending the form to the address in
24aabove.also submit a copy of this forts within 30 days of completion of well
12.Well construction method:HSA/Air Rotary cofstmctiuit to the following:
(i.e.anger.rotary,cable.direct push.ere:}
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
I3a Yield(gpm) Method of test: 24e.For Water Supply&[jection Wells:
Also submit one copy of tins form within 30 days of completion of
13b.Disinfection types Amount: well constriction to the county health department of the comity where
constructed.
Fans GW-L Nails Carolina E epaantcnt of Environment and Named Resources-Division of Waier Ft -ctirtEs Revised August 2013