GW1-2021-00376_Well Construction - GW1_20210315

prilnt Form
WELL CONSTRUCY10N RECORD (GW-1) For Internal Use(Ally:
1.Well Contractor Information:
Terry White 14.WATER ZONES
Well('mmedor Name FROM TO DESCRIPTION
3287-B z 1 s ^-
ft. fl.
NC Well Contmetor CertJcation Number IS OUTER CASING far�dtitared weW OR 13NER da ieahk
ETFROM TO DLU ETER CKNEffi hfATER AL
Company Name
WM0401277,0001-21-MW5-RWO I&INNERCASINGORTl®vc r.drincd-
2.YYell Construction Perndt#: FROM TO I DIAMETER THICKNESS MATERIAL
I�et as appleable»eu eonuraroon perma�rive ufc,Caunn,state, l a.ram,"err.) 0 ft. 5 M 'I 'n sch40 PVC
3.Weft Use(checlrwen use): fl• fl. in.
Water Supply Well: 17.SCREEN
FROM I TO I DIAMETER I SI.OTS]7,,F. I THICKNESS I MATERIAL.
.Agi,,db,ml []MlmicipalPublic 5 ^' 15 H- 1 'm 0.010 SCh40 PVC
Geothermal(ileating,Cooling Supply) [3Residenlial Wala Supply'(single) R ft in.
lodushral/Conmerctal [)Residennal Water Supply(shared) lIt GROUT
—11ringation PROM TO MATFRLAL EMPLACEMENT METHOD&AMOUNT
Nor-Water Supply Well: 0 ^• 3 ^• Bentonite POUred/7LB
x kloniloring IlRecovey ft. A.
Injection Well:
ft. n.
.Aquifer Recharge []Ckoundwater Rrnedianon
19.SAND/GRAVEL PACK(if appticabk
Aquifa Storage and Recovery [)Salinity Barrier FROM To MATFRIAI, EMPLACEMENT METHOD
.Aquifer Test ❑SYonnwabT Drainage 3 ^ 15 ^- #2Serld Poured
Experimental Technology 0subsidencecontoo, ft. I ft.
(:xdtermal(Closed Loop) E3Tmff 20.DRILLING LOG attach addmwal sbmb if
Geothermal 0 leatinwCooling Return) nOther(erplain under#21 Remarks) FROM To DESCRIPTION .cam h.,n..>;,ol� a.,.u.
^. ^- See Consultant Log
4.Date Well(s)Completed;2/23/2021 WcU ID#TM W-2 ft. fl_
So.Well Location:
Former Danials Cleaners R fl.
F.edrty Uwrer Name Facdip ID-(dappisal,k)
650 N. Main St. Highpoint, 27262 l 2021
Physical Address,City,and Zip n. R.
Guilford 21.REMARKS
County Parcel Idcmifwation No.(PIN)
56.latitude and longitude in degrees/minutes/seconds or decimal degrees:
of well field one latilong is sufficient) 22.(rrlificaliuu:
35 57 44.80 N 80 0 32.60 W 2i&w 6c),6& 3/9/2021
6.la(are)the we9(s)OPerinanent or )Temporary Sieiwlure Cenuid Well Cunnactor Dal,
By signing this fomt I hereby certify that the w H(s)was(were)consoacud in accordance
7.Is this a repair to an existing well: ❑Yes or )No wHh 15.4 NCAC 02C.0100 or 15A MCA,-02C.0200 W R Consmirhon Standards and that a
If this is a repair fr(f out lmown well mmarucnan inform iron and explain the nature ofthe copy of this remrdhas been proodedro the wzJf owner.
reparr,under#21 remarks secnon anon the back ofdrts form
23.Site diagram or additional well details:
R.For GeoprobeDPT or Owed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1(PW-1 is needed. Indicate TOTAL.NI-MBF.R of wells construe4ion details. You may also attach additional pages if necessary.
drilled.one SIiB%UTTAL INSTRUCTIONS
9.Taal well depth below land surface: 15 YL) 24a. Far All Wells: Submit this Corm within 30 days of completion of well
Far mulbplz wzlLc list a]7 depths rfd$zrent IaamQfe-la2'!IO'mul2yiduo� -
construction to the following:
10.Static water level below top of casing:2 (fl.) Division of Water Resources,Information Processing Link,
If wren level is above casing..,, ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 2 1 A (I-) 246. For Inieetion 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.Wen construction method: construction to the following:
(ie.auger.rosary,rnhle,direct push ek.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-16M
13a.Yidd(gpm) Method of test: 24c. For Witter Sutoph& Injection Wells: In addition to sending the term to
the addre o(a) above, also submit one copy of this form within 30 days of
13b.Disinfection type; Amount; completion of well construction to the county heahh dap em of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Resrsed 2-22-2016