GW1-2021-00374_Well Construction - GW1_20210315

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WELL CONSTRUCTION RECORD((;W-1) For Internal Use Oniv:
1.Well Contractor Information:
Terry White It WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
10 3287-B It. 20 ft.ft. R
NC Well Contractor Certification Number M OUTER CASING far 7altirared pHs OR I.117FJt a
IETPROM TO DIAMETER TMCKN63 MATER AL
2 fl. In
Company Name
WM0401279,0001-21-MW5-RWO IL INNERCA9SGOttT WIG r.ra
2 Well Construction Permit N: FROM To DIAMETER THICKN65 h4TTERLU.
Gsr aU applicable well ronstmcaon pennih p.e. LUC,County.Slate.Variance,e1c.) 0 R 5 IL m sch40 PVC
3.Well Use(check well see): ft. R- in
Water Supply Well: 17-SCREEN
FROM TO DIAMETER 5WT51ZE THICK1155 MATERIAL
.Agricultural �MmiicipalTublic 5 fL 20 f' 1 Ill 0.010 sch40 PVC
Cxothermal(Heating/Coohng Supply) Residential Water Supply(single) IL IL is
Industri d/Con mercial ❑Reside tial Water Supply(shared) It lalWR
—)Imgatim mom TO MATERIAL EMPLACEMENT METHOD as AMOUNT
Non-Water Supply Well: 0 "• 3 "- Bentonite POUfed/7LB
x Monitoring DRecovery
Injection Well:
fl. R-
AquiferRecharge ❑(koundwaier Remedialion
19.SAND/GRAVEL PACK d 'ode
..Aquifer Storage and Recovery OSahmty Barrier FROM TO MATERIM, EMPLACEMENT METHOD
Aquifer Test ❑Stoninxia"Drainage 3 "• 20 "- #2 Sand Poured
Experinasttal Technology Subsidence Control fl• I ft.
CRdhennal(Closed Loop) 0'1racer 20.DRILLING LOG Iattach iddb-ad rheeb b ueete
Geothermal(Healmg/Cooling Return) nOther(explam ,it.,ti21 Remarks) FROM To DESCRIPTION cep 5.N .aivr.eli a tut.
R. R See Consukant Log
tWteWeb(s)Completed:2/23/2021 WeBIDOTMW-5 R. R
n. fl.
Sa-Well Location:
Former Danials Cleaners R R
Facdity/Owmr Name Facility ID-(dapplsablc) "' R
662 N. Main St. Highpoint, 27262 " 9071
Physical.Address,City,arid Zip
Guilford 21.REMARKS
County Parcel Idenifwarm N. (PM)
51a.latitude and longitude in degreestmhnrt®/seconds or decimal degrees:
(If well field hie IeNong is sufficient) 22.l edification:
35 57 45.80 n 80033.60 w 21
3/9/2021
may U)�
6.*am)the web(s)OPerseent or %❑Temporary SignatutjorCerolied Well Contractor Date
By sVnnig rhir farm, I hereby mr fy dart tie wellio was(,hex)cavhackd in accordance
7.Is this a repair to an existing well: ❑Yes or ONo wah 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cmutrachon Standards and that a
tfdam is a repair,fro out knoxn w,U ro.0 ton information and e=plabt the nature ofdw copy of ther rerordhas been provialed b die well owner.
repair coder roll remar6'secnini or an the back ofthis form
23.Site diagram or additional well details:
S.For Geopmbe/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
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells consuuclion details. You may also attach additional pages if necessary.
drilled:one SUBINUTTAL INSTRUCTIONS
9.Total well depth below land surface: 20 (R-) 249- For AR Wells Submit this form within 30 days of completion of well
For mulnple wells 1.1 all depths ifahfferew(exampk-i id10a'un.121d/Iro') construction to the following:
10.Static%star level below top of casing: 10 (R) Division of Water Resoairl Information Processing Unit,
ryware.Izwl is abosv nosing,v:o- 1617 Mall Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter. 2 1/4 (w) 24b. For Injection Webs: In addition to sending the form to the address in 24a
IL Well construction method, Direct Push above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(i e.auger,rosary,cable,direct Peak ew)
Division or Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a-Yield(gpm) Method often: 24c- For Water SLonh& Injection Wells: 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 consum lion to the county health dcp an of the county
where constructed
Fah G W-I North Carolina Department of Environmental Qelity-Division of Water Resources Revised'_'-2.2016