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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Well Contractor Information: I
KENNY SARGENT la.WATER ZONES E E
Well Contractor Name FROM TO DESCRIPTION
ft. ft. C
A - 4226 ft. ft.
[ •
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a) licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
Z.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.171C,County,State,Variance,etc.) 0.0 ft• 125.0 ft' 2.0 ' in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 125.0 fl' 135.0 ft• 2.0 1n' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 78.GROUT ,.
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 117.0 ft' PORTLAND,BENTONITE SLURRY
Monitoring ❑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 ❑Stormwater Drainage 122.0 ft' 135.0 tr, 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0.0 ft• 2.0 ft' ASPHALT/GRAVEL
4.Date Well(s)Completed: 12/02/21 Well ID# AMW-21 D 2.0 ft• 20.0 ft' BROWN SILTY CLAY
5a.Well Location: 200 ft. 31.0 ft. BROWN SILTY PWR
FLOW ACURA/BMW 31.0 ft' 135.0 ft• GRAY ROCK
Facility/Owner Name Facility lD#(if applicable) ft. ft. i--
3908 WEST WENDOVER AVENUE GREENSBORO 27407 ft. ft. MAR Y 1707'
Physical Address,City,and Zip ft. ft.
GUILFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 117.0-122.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36° 03' 38.59" N 79° 52' 43.76" W J i, l ,A '- 12/06/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the Ire//owner.
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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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 135'0 (ft.)
For multiple wells list a//depths if different(example-3@200'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
10.0 24a. For All Wells: Original fohn to Division of Water Resources (DWR),
10.Static water level below top of casing: _ (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use'4"
11.Borehole diameter: 6.0 (in,) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (lUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
24c.For Water Supply and Open'Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: ` '`
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20I8
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