GW1--02080_Well Construction - GW1_20240405

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
Virgil Wilson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I
4473A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. ; in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO ` DIAMETER THICKNESS _ MATERIAL
2.Well Construction Permit#: 0 ft 3 ft- 2 in. sch40 pvC
List all applicable well permits(i.e.Cmmty,State,Variance,Injection,etc.) -
ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 f` 18 to 2 '"' 010 sch40 pvC
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO , MATERIAL EMPLACEMENT METHOD&AMOUNT .
❑irrigation 0.5 ft 1 ft Portland Cem Tremie
Non-Water Supply Well: -
❑+Monitoring ❑Recovery 1 ft 2 ft Bent. Chips Poured
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO IATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 2 ft 18 ft #1 Sand •
Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft.
3-19-24 MW-1 A ft ft.
4.Date Well(s)Completed: Well ID#
ft ft : ..a,j
5a.Well Location: ft. ft.
BP BP 450 ft. ft S R O 2G24
Facility/Owner Name Facility ID#(if applicable) ,-
1922 West Main Street, Durham 27705 ft. ' ft. h,�;,;,J , a,-;�.,;�,"` �,`
ft. ft. I;.'rt1, iLJt�
Physical Address,City,and Zip
21.REMARKS
Durham 8"Flush Mount Cover Installed
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.C 'ficati n:
(if well field,one lat/long is sufficient)
36.006887 N -78.922032 W �, 0,.........t.k..),
S D
Signature of ertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby cen fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back 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 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the scone construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 18 (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@I00') construction to the following:
10.Static water level below top of casing: Unknown (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 Infection Wells ONLY: IIn addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: HSA, 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
24c.For Water Supply&Injection)Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
' constructed. 1
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013