GW1--03053_Well Construction - GW1_20230310

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. Opper FR WATER ZONES
FOM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THTCKNESs MATERIAL
Regional Probing Services ft. fL in.
Company Name 16.INNER CASING OR TUBING(geothermalclosed loo
Guilford 2023-02-06-MW-4-RWO FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 it' 5 ft. 1 in. sch 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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 f`• 20 ft• 1 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fLin. I
❑Industrial/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:
2Monitoring ❑Recovery 3 f`' 4 ft• bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Reinediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Storage and Recovery []Salinity Barrier
4 ft- 20 tr• #2 sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 DRILLING LOG attach`additional'sbeets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/r•ock type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 20 ft. Silty Sapd over saphrolite
4.Date Well(s)Completed: 2/9/2023 MW-1, MW-2 ft. ft.
ft. ft.
MIR
� 77
5.Well Location: ft. fr.
Culp, Inc. ft. ft. -:1_- 1
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1150 Silver Court, High Point ft. ft.
Physical Address,City,and Zip
21:=REMARKS
Guilford
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification 1 cigiwog
(ifwell field,one lat/long is sufficient) a nee Natob yser a w,
35.9250653 N 80.0034114 W Opper "' ""�""°"" `"" 3/2/2023
-115--
j' Date 30Z3Di0116d1:3305'00'
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 JPell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 2 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY 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 multiple wells list all depths if di ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 5 (ft.) Division of Water Quality,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2.5 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Geoprobe DPT above, also submit a 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 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 SuuDly&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013