GW1--06955_Well Construction - GW1_20231027

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Scott M.Werley 14.WATER ZONES
WeIlContractorName FROM TO DESCRH•TION
3344-A 6.0 ft. 10.0 ft- 9,,,i,ery
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
ECS Southeast, LLP FROM TO DIAMETER THICKNESS I MATERIAL.
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:
WM0501585 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 5.0 fi. in.
3.Well Use(check well use): ft. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT sum THICKNESS ''MATERIAL.
Agricultural OMunicipal/Public 5.o ft- to.o ft- 2 in. oto schao PVC
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) IS.GROUT
Irrigation FROM TO __ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
x Monitoring ()Recovery ft. ft.
Injection Well:
IL It.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage 3 ft• to ft. #2 silica sand pour
Experimental Technology °Subsidence Control o ft. 3 ft. bentonite pour
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soil/rock type,grain sire,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) •
0 ft• 4.0 ft• brown mottled with orange silty clay
4.Date Well(s)Completed: 10/6/2023 Well ID#TW-2 4.0 ft* 10.0 n.
p gray silty clay
5a.Well Location: ft. ft.
IBM N/A ft. ft. ,_ ,
Facility/Owner Name Facility ID#(if applicable) ft. ft. '1...k..-,,,,_;L...1 i`: ..
4205 South Miami Blvd, Durham, 27703 ft. ft. OCT 2 7 Z023
Physical Address,City,and Zip ft. ft.
Durham 157755&157802 21.REMARKS . .'' •=447.44-'J 01',`
►n:. . `.(,i i..:.Ls:',:Xx
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.899211 N -78.845752 W (� ��/
\ trtor
1 0/1 9/2023
6.is(are)the well(s)DPermanent or XOTemporary Signature of Certified We Date
By signing this Jorm, 1 he y certtJir that the well(s)was(were)constructed in occordanrc
7.Is this a repair to an existing well: °Yes or E2 No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
(this is a repair,Jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2/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 t 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: 10.0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 6.0 (ft.) Division of Water Resources,Information Processing Unit,
limiter level is above casing,use"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.25 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
hand 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 Sunuly&Injection 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016