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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: l
KENNY SARGENT 14.WATER ZONES I
Well Contractor Name _FROM TO DESCRIPTION
ft. ft.
A - 4226 ft. ft. I,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
GEOLOGIC EXPLORATION FROM TO DIAMETER: THICKNESS MATERIAL
ft. ft. 1 .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.U/C,County,State,Variance,etc.) 0.0 ft• 90.0 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 90.0 ft• 100.0 ft. 2.0 in' .010 SCH 40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 83.0 ft' PORTLAND BENTONITE SLURRY
19Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEM ENT METHOD
❑Aquifer Test ❑Stormwater Drainage 88.0 ft• 100.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING,LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 2.0 ft' ASPHALT/GRAVEL
4.Date Well(s)Completed: 11/30/21 Well ID# AMW-8D 2.0 ft• 15.0 ft' BROWN SILTY CLAY
5a.Well Location: 15.0 ft' 19.0 ft' BROWN SILTY PWR
FLOW ACURA/BMW 19.0 ft• 100.0 ft' GRAY:ROCK
ft. ft.
Facility/Owner Name Facility ID#(if applicable) 1' -
3908 WEST WENDOVER AVENUE GREENSBORO 27407 ft. ft. MAR
Physical Address,City,and Zip ft. ft. 2027
GUILFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL'83.0 88.0;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 .I,,,,/ j)-.~;.-7- 12/06/21
6.Is(are)the well(s): TWermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or EINo I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 421 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: . 100.0 (ft.)
For multiple wells list a//depths ifdifferent(example-3 rr 200'and 2GJ100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 1 5.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6.0 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
SONIC i
12.Well construction method: 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018