GW1-2022-08570_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 3098 KLUE4VED ft. rt.
gg ft. ft.
NC Well Contractor Certification Number MAY ej 202_
o / '15.OUTER CASING for multi-cased'wells OR LINER(if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name 1 �g��1 'f,C, ft. ft. in
DtAVBOG 16.'INNER CASING OR TUBING eothermal dosed-loo
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 25.0 ft. 2.0 1° SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: -17.SCREEN, a•�.y , s
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 1" 30.0 ft 2.0 in- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial' ❑Residential Water Supply(shared) 18.GROUT
❑IIrI ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 21.0 ft PORTLAND aENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
-19.SANDIGRAVEI;PACK if a licatile" •"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 23.0 ft- 30.0 ft- 20-40 FINESILICASAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ..20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) 11Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soiUmck type,grain size,etc.
0.0 ft. 0.5 ft. CONCRETE
4.Date Well(s)Completed: 04/12/22 Well ID# AS-1 0.5 ft. 1.0 ft. GRAVEL
5a.Well Location: 1.0 ft 18.0 f" RED/ORANGE CLAY
BILL MARION 18.0 ft. 30.0 1" BROWN SILTY CLAY
Facility/Owner Name Facility ID#(if applicable)
I
-- ft. -- - - - ----- - -
4557 PLEASANT GARDEN ROAD GREENSBORO 27406 ft. ft.
Physical Address,City,and Zip ft. ft.
GUILFORD z1.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-21.0-23.0 FEET
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***AIR SPARGE***
(if well field,one latllong is sufficient) 22.Certification:
350 58' 19.01" N 790 45' 56.45" W 04/25/22
6.Is(are)the well(s): I191'ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A 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 ofthe ofthis record has been provided to the ivell owner.
repair under 921 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 1 GW-I 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: 30.0 (ft.)
For multiple wells list all depths ifdi/ferent(example-3 a 00'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
20.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
If water level is above casing,use"+"If Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in,) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
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 producing.over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018