GW1-2022-01787_Well Construction - GW1_20220214

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1 Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
ban lei Su Infers 14.WATER ZONES
d �-
Well Contractor Name IO FROM TO DESCRIPT N
2579-A
PCEIt j ft 3 EI) 15 0 1
ft
B ft ft 4
NC Well Contractor Certification Number 4 2e?? 15.OUTER CASING for multi-cased wells OR LINER if a' li Able ,
Carolina Soil Investigations L FROM TO DIAMETER THICKNESS MATERIAL
' 6 a�`awm D...`---' -•• 0 ft 1 15 ft 2 j in. I sch 40 pvc
Company Name
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: Guilford#006-00-MW13-RW3 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft ft in.
3.Well Use(check well use): fL ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural I Municipal/Public 15 ft 30 ft 2 in. 010 sch 40 pvc
E3 Geothermal(Heating/Cooling Supply) I Residential Water Supply(single) ft ft in
0 Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNTS
Non-Water Supply Well: 0 ft 5 ft• portland mix&Pour
®X Monitoring Recovery 5 ft 13 ft bentonite tremie
Injection Well: ft ft
Aquifer Recharge Groundwater Remed iation
19.SAND/GRAVEL PACK.if applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stormwater Drainage 13 ft 30 ft 10/30 silica sand tremie
_ Experimental Technology 0 Subsidence Control fa ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG fiittach additional sheets if necessary)
Geothermal(Heating/Cooling Coolin Return) FROM TO DESCRIPTION color,hardness,soiltreck rain sire etc.
( g/ g ) �Other(explain under#21 Remarks).
07/20/2021 MW-4RR 0 ft 30 ft brown silt loam/brown silty clay/saprolite
4.Date Well(s)Completed: Well ID# ft ft
5a.Well Location: fL ft
[Rockwell] Allen-Bradley Facility ft ft
Facility/Owner Name Facility ID#(ifapplicable) ft ft
5925 Summit Ave Browns Summit; NC fL ft
Physical Address,City,and Zip
ft ft
Guilford 21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.17716 N -79.71532 W
07/20/21
6.Is(are)the well(s):E]Permanent or E]Temporary Signature of .tified well ' ctor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Elves or® No 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#21 remarks section or on the back r f 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 Ito provide additional well site details or well
construction,only I GW-1 is needed.Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary.
drilled: 1
SUBMITTAL INSTRUCTIONS j
9.Total well depth below land surface: 30 (ft.)
For multiple wells list all depths if different(example-3@200'and 2 a 100') 24a. For All Welts: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top ofcasing: 23 (ft.)
If water level is above casing,use"+ Division of Water Resources,Information Processing Unit,
$„ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b. For Infection Wells: In addition to sending the forth 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
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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018