GW1--06956_Well Construction - GW1_20231027

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WELL CONSTRUCTION RECORD(CW-1) For Internal Use Only:
1.Well Contractor Information:
Scott M.Werley 14.WATER ZONES
Well Contractor Name FROMro DESCRIPTION
0.5 ft. 4.0 ft- .,,t a,,,,,,clayey sa t
3344-A
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. Ir
Company Name
WM 0501585 16.INNER CASING OR TUBING(geothermal closed400p)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM It) DI\METER SLOT SIZE THICKNESS MATERIAL
QAgricultural QMunicipa[/Public o ft. 4 ft. 2 in oto Sch 40 Pvc
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
OIndustrial/Commercial DResidential Water Supply(shared) 18•GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring _Recovery ft. ft.
Injection Well:
ft. ft.
0Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT MF:1lion
Aquifer Test jStomtwater Drainage o R. 4 ft- #2 silica sand pour
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Ei 1-,,user 20.DRILLING LOG(attach additional sheets if necessary)
FROM '1'0 DESCRIPTION(color.hardness.soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) FtOther(explain under#2l Remarks)
0 ft• 0.5 ft• light brown silty clay
4.Date Well(s)Completed: 10/6/2023 Well ID#TW-1 0.5 R. 4 0 ft.
plight brown clayey sand
5a.Well Location: ft. ft.
IBM N/A ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4205 South Miami Blvd, Durham, 27703 ft. ft. ---,-}..--- f
Physical Address,City,and Zip
ft. ft. v a, R., fi...
Durham 157755& 157802 21.REMARKS 0 C j 2 7 iUZ3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: In'-+'" tif��JW�re 44 •`..
(if well field,one let/long is sufficient) 22.Certification:
35.899211 N -78.845752 ( --
W \ 10/19/2023
6.Is(are)the well(s)0 Permanent or OTemporary Signature of Certified Well Con c r 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: OYes or E3 No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this 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 forts.
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 I GW-I 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: 4•0 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I001 construction to the following:
10.Static water level below top of casing: 0'S (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: 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 Supply& 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 Ens ironmental Quality-Division of Water Resources Revised 2-22-2016