GW1-2022-01786_Well Construction - GW1_20220214

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Print Forme
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
15anlel SUmrTlers 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name i�
10 fL 20 fL
2579-A FEB 14 2M fL fL
NC Well Contractor Certification Number
Lam` - � ft unk 15.OUTER CASING for mWtitased wells OR LINER if a licable
Carolina Soil Investigations, LL11V^`��' FROM TO DIAMETER THICKNESS MATERIAL
� A 0 fL 10 fL 2 SCh 40 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: Guilford #006-00-MW13-RW3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.71C,County,State,Variance,etc.) fL fL in.
3.Well Use(check well use): fL fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
n Agricultural 0Municipal/Public 10 ft 20 ft. 2 in• 010 SCh 40 pVC
Geothermal(Heating/Cooling Supply) l Residential Water Supply(single) fL ft. in.
0 Industrial/Commercial F1 Residential Water Supply(shared)
® 18.GROUT
Irrigation
Q Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 5 fL portland mix&Pour
®X Monitoring ®Recovery 5 fL 8 fL bentonite tremie
Injection Well: ft f4
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL-PACK ifapplicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
_.Aquifer Test Stormwater Drainage 8 fL 20 fL 10/30 silica sand tremie
Experimental Technology Subsidence Control fL ft.
Geothermal(Closed Loop) El Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillmck type,zrain sin,etc.
07/20/2021 MW-12R 0 fL 20 fL brown silt loam/brown silty clay/saprolite
4.Date Well(s)Completed: Well ID# fL ft
5a.Well Location: ft fL
[Rockwell] Allen-Bradley Facility ft ft
Facility/Owner Name Facility ID#(ifapplicable) fL ft
5925 Summit Ave Browns Summit, NC ft ft.
Physical Address,City,and Zip
fL fL
Guilford
21.REMARKS '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 2Z.Certification:
36.17678 N -79.71735
07/20/21
6.Is(are)the well(s):X®Permanent or O Temporary Signature .artified We ( ctor ! Date
7.Is this a repair to an existing well: Yes or NO By signing this fonn,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0100 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 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 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: 1
SUBMITTAL INSTRUCTIONS
9.Total:well depth below land surface: 20 (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 1@100') 24a. For All Wells: Submit this':form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 13 (ft.)
lfwater level is above casing,use"+ Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: $n (in.)
24b. For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: auger above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c. For Water Supply& Infection 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-I North Carolina Department of Environmental Quality-Division ofWater Resources4 Revised 6-6-2018