GW1--05328_Well Construction - GW1_20240906

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Michael B. Moseley 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
f
4356ft. .
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if apIMATERIAL
cable)
Summit Design and Engineering, Inc. FROM TO DIAMETER THICKNESS
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.(//C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL___
Agricultural 0Municipal/Public 12.1 ft. 71 it 2 in' 0.010" PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in. -
Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&A.MOUNT
Non-Water Supply Well: 7.0 ft 3.5 It bentonite chips
x Monitoring 0 Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable) -
Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 12.1 ft- 7.1 ft. No.2 Sand
-
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.)
ft. ft.
4.Date Well(s)Completed:7/26/23 Well ID#B-42 ft. ft.
ft. ft. ` 1
5a.Well Location: l_ }`
A-1 Sandrock ft. ft. SEP
Facility/Owner Name Facility ITN(if applicable)
ft. ft. 2014
2091 Bishop Road, Greensboro 27406 ft. ft. Inferrf.:,4471 iv,- ,
Physical Address,City,and Zip ft. ft. DN(;d4f .S Wit
Guilford 21.REMARKS
County Parcel Identification No.(PIN) no well pad or cover installed per client request
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
35.987150 N -79'847409 W
6.Is(are)the well(s)UjPermanent or )Temporary Signature of Ce edcWell Contractor Date
Hy signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or DINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under'12/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: 12.1 ft.
P ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@l00) construction to the following:
10.Static water level below top of casing:DRY (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"•" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:3.25 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
auger 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
13a.Yield(gpm) Method of test: 24c. For Water SnDDIV& 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