GW1-2022-08415_Well Construction - GW1_20220502

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. Opper 14.WATERZOAEs -
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
NC3322-A
NC Well Contractor Certification Number 15.OUTER CASING formtt'-cased Wells OR LINER f a °li
FROM DIAMETER THIKNES MA RIAL
Regional Probing Services rt. ft. "•
Company Name 16.INNER CASING ORTUBING, eothermal closed400
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 f" 5 ft. 2 1"• seh 40 PVC
List all applicable well construction permits(i.e.County,.State,Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 u. 20 rt, 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. tt. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft. cement grout pour
Non-Water Supply Well: 3 ft- 4 ft- bentonite pour
@Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK'ifapplicable)`
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
4 rt• 20 ft. #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attachadditionaliIheetsifnecessary;--
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock b e,gmin sim,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rL 20 ft silty sand over saphrolite
4.Date Well(s)Completed:
2/21/2022 T-M W-8
ft. ft. I
5.Well Location:
A Cleaner City/Tops Cleaners DSCA DC410023/DC410051
rt. ft.
Facility/Owner Name Facility ID#(ifapplicable)
2804 Battleground Avenue ft ft P D
Physical Address,City,and Zip 21.REMARKS
Greensboro a(A.�fm -
02
County 4 Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification: „_ n
(if well field,one ladlongissufficient) aaayaignjbyow®nceopper �y lytyi ;�1j-;,;�(',i,;nils.��'vJV1' !
Lawrence O G N:cn=awrees,ou, er,o=Regional
36.107219 N 78.833274 W pp emailri ywegionalpmbing-,c=US 3/22/22
Signature of Certified Well Contractor Date ,
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify thal'the ue/l(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction.Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
lfthi.s is a repair,fill out known well construction information and explain the nature of 1he
repair under#21 remarks.section or on the bock afthisjorm. 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 ifnecessary.
For multiple injection or non-water supply wells ON/_Y with the same construction,you can
.submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nwlople wells list all depths tfd erem(example-3C700'and 2@100') construction to the follow mg:
10.Static water level below top of casing: approx 10 (ft) Division of Water Quality,Information Processing Unit,
I/'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 4.5 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
Auger above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Geothermal Wells: In addition to sending the forum 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.
I ,
Fort»GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013