GW1-2022-08572_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 DES ON
A - 3098 ft. ft.
ft. ft
NC Well Contractor Certification Number IS.,OUTER'CASING for mold-cased.'ells OR LINER`ifa licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name x4 tr
16.INNER CASING-OR TUBING eother at closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,Co , tat,45710, .) 0.0 ft. 10.0 ft. 4.0 in. SCH 40 PVC
3.Well Use(check well use): a ft. ft. in.
IntorFna;+on i-r��„�s,,..g Urea
Water Supply Well: URMG "17.SCREEN" •
'
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 10.0 ft' 25.0 ft. 4.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It. 6.0 ft. PORTLANDBENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL'PAC K ifa ticable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 8.0 ft. 25.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) In Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soil/riicktype rain size,etc.
0.0 ft• 0.5 ft. CONCRETE
4.Date Well(s)Completed: 04/12/22 Well ID# SUE-1 0.5 ft- 1.0 ft. GRAVEL
5a.Well Location: 1.0 ft. 12.0 ft. RED/ORANGE CLAY
BILL MARION 12.0 ft- 25.0 ft. BROWN SILTY CLAY
Facility/Owner Name Facility ID#(if applicable) ft. ft
4557 PLEASANT GARDEN ROAD GREENSBORO 27406 ft. ft.
Physical Address,City,and Zip ft. ft
GUILFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-6.0-8.0 FEET
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***SOIL VAPOR EXTRACTION***
(if well field,one latlong is sufficient) 22.Certification:
350 58' 19.01" N 790 45' 56.45" W 04/25/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the wells)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [ENo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known ivell construction information and explain the nature ofthe ofthis record has been provided to the ivell owner.
repair under#21 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-1 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: 25.0 (ft.)
For multiple wells list all depths ifdii ferenr(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifivater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
10.0 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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