GW1-2023-02849_Well Construction - GW1_20230418

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Alton Boshoff °1,4,,WATER,ZONES .
FROM TO DESCRIPTION
Well Contractor Name
8 ft- 15 ft* soma moi—soma,era mrarot
NCWC 2595-A
ft. ft. ,
NC Well Contractor Certification Number ;15.`OUTER CASING(foe inuIti-cased°welts-URLINER ifa"' licabl"e-.
Geo Support, Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
2023-03-01—MW1—RWO I&INNER CASING ORTUBING� eothermalclosed-1oo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. g ft. 2 in. SCH 40 we
3.Well Use(check well use): ft. ft. in
Water Supply Well: FROMREE TO DIAMETER '^SLOT SIZE THICKNESS MATERIALr3
Agricultural []Municipal/Public 9 ft, 19 ft. 2 in. 0.011, SCH40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) i&GR011T
2Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 3 ft. Portland Cement Pour
•c nA,,..:.<'i n_ _ r t []Recovery 3 ft-- 7 ft, Hole Plug Pour
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
'19 SAND/GRAVEL PACK"if a licable "
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [DStormwater Drainage 7 ft. 19 ft. #2 Sand Pour
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 10 DRILLING LOG attach additional ifnecessa _,.
Geothermal(Heating/Cooling Return) ClOther(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soilfrock type,grain sve,etc. \
0 ft. 8 fL Brown clay
4.Date Well(s)Completed:3/17/23 Well ID#MW-1 8 ft. 17 ft. Light brown sandy clay
5a.Well Location: 17 ft. 19` ft. Very hard light brown to grey,sandy clay
Ki Kim ft ft.
ft ft.
Facility/Owner Name Facility ID#(if applicable)
1530 Woodmere Dr, Greensboro, 27405 ft. ft.
non o 23
Physical Address,City,and Zip
ft ft. " 1
Guilford '2tREMARKS - s t
County Parcel Identification No.(PIN) Auger refusal at 19'. Limited water noted irl.thb,4ellTn1tially. Give time to
charge.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certific on:
36deg 5'49" N 79deg 45' 11" W 11 4/14/2023
6.Is(are)the well(s) Permanent or X Temporary Signature of Certified Well Contractor 101,11
Date
By signing this form,I hereby cert that th7(j,)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or XX No with15ANCACO2C.0100orl5ANCACO2 Well Construction Standards and'that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the wner.
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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 19 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 7.95 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 5 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rotary Drill above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) Method of test: 24c. For Water Supply&Iniection 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 construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016