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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES l t
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I
A - 4459
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop) .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 3.0 ft. 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3.0 ft. 9.5 ft. 2.0 in' .010 SCH 40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 1.0 ft. PORTLANDBENTONITE SLURRY
t!JMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 2.0 ft• 9.5 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 0.5 ft' CONCRETE
4.Date Well(s)Completed: 02/17/22 Well 1D# MW-15 0.5 ft. 6.0 ft• FILL
5a.Well Location: 6.0 ft' 93 ft' PWR
SPEEDWAY - 6954 ft. ft.
Facility/Owner Name Facility IDti(if applicable) ft. ft. MAR 1 / 7O2.-
801 WEST FAIRFIELD ROAD HIGH POINT 27263 ft. ft.
Physical Address,City,and Zip
ft. ft.
GUILFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL 1:0 2.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long in sufficient) 22.Certification: �;
35° 55' 13.14" N 80° 00' 02.65" w ��„�",�/ / ,•2- 02/18/22
6.Is(are)the well(s): !Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the we/l(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo I5A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 421 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 9'5 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if d erent(example-3 tt 200'and 2 r@100)
10.Static water level below top of casing: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+'•
I
11.Borehole diameter 8.0 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
AUGER !
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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