GW1-2021-00375_Well Construction - GW1_20210315

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WELL CONSTRUCTION RECORD((;W-1) F'or Internal Use(filly:
1,welf Contractor Information:
Terry White 14.WATER ZONES
FROM TO DESCRIPTION
U'dl Conuactor Nemc 1
5 20 n.
3287-B ft.
NC Well Contractor Certificazron Number IS OUTER CTING forndtirand welt
AET OR LINER des
FlICKNE6 MATER AL
fl. ft. to
Company Name 1&1NNER CASING OR TUBING real clawed-
, WM0401276,0001-21-MW5-RWO FROM TO DLAMETF.R CKNESS MATFR AL
2.Well('mstrrwYbn Pernit d:
Lot a0 applcable well constrvction permits(ie. UIC,County,State, t"nonce,ery 0 "' S fl. in se1140 PVC
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DLUIETER SLAT SV.E I THICKNESS MATERIAL
.Agricultural �MtmicipaFPubhc 5 ft 20 ft 1 'a 0,010 SCh4O PVC
C-dhermal(Healing/Cooling Supply) Residential Water Supply(single) ft ft tip
In&wtriaVComnlercial Residential Water Supply(shared) IS GROAT
ipl FROM I TO i MATEWA I EMPLACEMENTMEIHOD&AMOUNT
Non-Water Supply We": 0 "- 3 " Bentonite POured/7LB
K Monitoring Recover' fl• "•
injection Well: n. n.
.Aquifer Recharge []Gromodwaler Remediation
19.SAND/GRAVEL PACK a 'obk
Aquifer Storage and Recover' Salinity Bartter FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stornwater Drainage 3 "• 1 20 "• #2 Sand Poured
Fxperimemal'lechnology Subsidence Control ft. I rL
Cn,othermal(Closed Imp) OTracer 20.DRILLING LOG at1:h additle al r b ft 7
Geothermal(HealinggyCooling Return) nOther(explain under n21 Rernarks) FROM fl TO fl DESCRIPTION rape.hard. wfll o ar ell.
See Consultant Log
a Date well(,)Completed:2/23/2021 WCH IDaTM W-3 n. n.
n. fl.
5a.well Location:
Former Danials Cleaners
Faeday-Owner Name Pacrho lDn Inapplicable) "' "•
441 N. Wren St. Highpoint, 27262 "
fl. ft.
Physical Address,City,and Zip
Guilford 21.REMARKS
County Parcel Idenffe,,n m No.(PIN)
5b.Latitude and longitude in depees/minutes/secoods or decimal degrees:
,it well field one lot long is sufficient) 22.(ertirtealiun:
35 57 45.80 N 80032.30 W T 3/9/2021
6.Islam)the wel(s)OPermmamt or %❑Temporary S,gneuu, C'cmilied Well C'ontmcnr [)me
By ognmg despot, I hereby rertay,row the.e11(s)was(.vrel conamcied ui acwralaw,
T Is this a repair to an existing we": Yes or jNu with 159.NCAC 02C.0100 or 15A YCAC 01C.0100 Well Construction Standards and that a
f pins is a repair,fill out brown well m rmicnon atformmton and explabr the nature of the copy of this rerord has been provided to the well cwner.
repair under 011 remarks section or on the back of this form 23.Site diagram or additional well detail,:
&For(;copmbe/DP'f 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-1 is needed. Indicate TOTAL.NUMBER of wells construction details. You may,also attach additional pages if necessary.
dolled:one SUBNHTTAL INSTRUCTIONS
9.Total well depth below land surface: 20 (R) Zia. For All Wells: Submit this from within 30 days of completion of well
Ib,multiple we&list all depths fdtf(erens(eramp@-346100 .at 11,b 100) construction to the following:
10.Static water level below top of casing:15 (M) Division of Water Resourees,Information Processing Unit,
!Came lei l is abosv casing.to, 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.2 1/4 (fit) lib. For Injection Wells: In addition to sending the form to the address in 24a
Direct Push above. also submit one copy of this form within 30 days of completion of well
12.Well construction method: constmction to the following:
o e.auger,rotary,cable,direct posh etc)
Division of Water Resourxes,l'rderground Injection Con"Pmgralu4
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service('enter,Raleigh,NC 27699-1636
13a.Yield(gym) Method of test 24c.F'or Water Supply& lnteetian W eils: 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-1 North Cmolim Department of F.nvirorunental Amity-Division of Water Resources Resrsed=22-2016