GW1--07725_Well Construction - GW1_20231122

.. . .
. :.. • .. . �.Print:Form'.l
WELL CONSTRUCTION'RECORD(GW-lj - ' For Internal Use Only: • .
' • ' 1:Well Contractor Information:' - - • • • • • •
.- : 15at1 a7ie1 ff:nrliers ' :. 14.WATER•ZONES..• 1.
c
Well Contractor Name "
FROM' _'TO'• DES RIPTION
5 :rt. 18. ra •
. 2579=A:
.. NC Well Contractor Certification Number . • : _' .-
15.OUTER CASING(for multi;cased Wells)"OR LINER(if an licable)
-- .Carolina.Soil Investigations, LLC" : • • FROM. TO DIAMETER THICKNESS' .MATERIAL ..
Company Name • • • • 0':.: •ft 5 •. •ft. : . .2 t :In.' • sch 40 pvc
It, • 16.INNER CASING OR TUBING(geothermal closed-loop) -
•.2.W_ ell Construction.Permit#,:WM0501597. : : FROM - TO - 'DIAMETER ..THICKNESS 'MATERLAL •
.• . List all applicable well construction permits(1 e.UIC.County,,State.Variance;etc.)' : .. . : '. :ft.' • ft-. •-• . .. :ID:.• • .. ,
.3.Well Use(check well use):• ' ft.. . `.fr.' : _ in.• . : ;
-Water Su 1 Well:. .. 17.SCREEN
PP Y •FROM. ' TO' DIAMETER SLOT SIZE. THICKNESS. -MATERIAL ..
. �A cultural_ • :0 MunicipalPublic. ' ' . : fL.'. iu
gr'. '. •' . 5-ft.. �'18 ' . 2 '.;• ;.010 , ' sch40'': :pvc. .
O'Geothermal(1•-leating/Cooling Supply). •D Residential Water Supply(single) ' .
•
. . • 0 Industrial/Commercial : ' 0 Residential Water Supply(shared) ' ' ' • • • • '•
18:GR it',. ,
ft. ft.'
- Irrigation Wells>;100;000GPD.• . ,FROM. . • TO ' , . . MATERIAL• EMPLACEMENT METHOD&AMOUNT . '
Non-Water Supply Well: 0 : •' . 3 .:rt.• portland: mix&Pour. • • ... ..
Monitoring .' 0 Recovery' ' . • ft.
®. . ,.. . 3.'- 4. ti bentonite :tremie
Injection Well: iG it.
' Aquifer Recharge • : : " ' 0 GroundwaterRetnediation: •
S RSAND/ TOLPACK( TEIle).
jAgtifer.StorageandRecovery 0alnityBarrier, , •FO - MARA EMPLACEMENTMETHOD
QAquifer'Test• . :' • ' " El Stormwater Drainage.... _ . • , •4::,t<: ::18 ft ;10730 silica sand: • :." tremie- • • '
0 Experimental Technology El Subsidence Control :• rt. fi..
. :.O'Geothermal(Closed Loop) : .• ::1]•Tracer... •. . • ' 20:DRILLING LOG(attach additional sheets if necessary) ' " •
1'Geothermal(Heating/Coolirig Return). .Other(explain under:421 Remarks) ,• .FROM•' TO -, -DESCRIPTION(color,hardness col/rock typo grain size,etc.)
.. .. • ' 0'- ft• . .3 '-fa' . - • orange brown:clay(moist)
4.Date Well(s)"Completed:10-05r23 ' . Well;ID# MW-4R tt, • n
:3 18 red orange•sli htl sand silt cla moist-wet
:• " • :Sa:'Well Location: -: . - : • :. : . .- ..ft. .-- ft. ' - • • • - - •-
. .� . Former Pantry#3093. . :.. : - : :: . : ft. .•ft. ' - .
• . •Facility/Owner Name: - ' . . ' Facility ID#(ifapplicable) • . .
it ft. R.�
3223.NCH 55 Durham' NC am:� ice."T-�1., ,; .�
'. ' Physical Address,City,and Zip _ .
Durham .. ' ft Al• NOV 2 .? 2023
- - . .. 21.REMARKC�• .. '
County. :: • . 'Parcel Identification'No..(PIIs0 • . •• • - c,�-<..2"- j ' _ -
• Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: . . - -• ;; • :• ' '
(if well field,one lat/long is sufficient) . . .
Z2.Certification: .
- :35.9.3414. - ' 78.88756 - : .
N. ' - w . . ' � '
� �10 05.23 . .. :
: : 6:Is(are)the well(s):2 Permanent.' or•0 Temporary,' : .. : : ' '
• Signature of Certified Well Contractor • Date
7.Is'this a repair to.an existing well: Yes or .NO: .By signing this form,I hereby certify that'the Well(s)was:(were)constructed in'accordance
..with 15A:NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
- If this is:d 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#2I remarks section or on the back of this form. ' : . . • ' . ' .' - . ' .' I : . . • •-
. • :. . . ,.. - .
' • 23.Site diagram or:addttional 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 , -
constniction,only 1 GW.-1 is needed.Indicate TOTAL NUMBER of.wells : '.' construction:details:You may also'attach additional page's if necessary.,
.drilled: ... .�.
• '.. . - • •. - : . . . • • SUBMITTAL INSTRUCTIONS
9.Totalwelldepth below land surface: ' '• .. 18- : :. • ' : . (ft.): •• - . .. : . . -: • , i'. , •- -' :• . •
.: For Multiple wells list a!!depths.if dierent"(example-3@200:and'2@100') '. ' ' . 24a..For All Wells:'Submit'this,form within 30 days of completion of well ' .
. conStuction.to the following:. • f -
• " . : .10.Static water level below top of casing: '.. • 9 : (fir)
• If woter level is above casing,use:"+" • • •• ,' . Division of Water..Resources,Information Processing Unit, .
8,,. . . • •' .• 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.Borehole diameter: . .. . . (in.) . I
. .
24b.'For niection Wells::In addition to sending.die fom:t ro'the address in 24a.
T2.Well construction method: .:au9er -.. . . .• above•also submit one" 'copy of this!form within 30 days'of completion of;well"
(i.e.auger,rotary,cable,direct push,etc:) wing: o I -
construction to the following:
" , . .. . ces,pUndergrou d•Injecti of Program, .
Division
'of Water Resour n oa Control
. FOR WATER SUPPLY WELLS ONLY:• • • 1636 Mail Service Center,Raleigh,NC 27699-1636 • . -
• ' 13a.Yield(gpm) - • • • ' ..Method of test: - 24cFor.Water Supply&Injection Wells:: In addition to sending the form:to• • ,
'' ' . the.address(es);above; also 'submit l one copy of this form within 30 days•of •. .
•
•
13b.Disinfection type: • • • Amount: . . • • completion•of well constriction to the county health department of the county. '
• : • ,whereconstructed: . . . ' .
Form GW-1 North Carolina Department of Environmental Quality-Division of WiterResources - • Revised 6-6-2018.