GW1-2022-07704_Well Construction - GW1_20220811

WELL CONSTRUCTION RECORD For IntemaI Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
�W:itiO'iFiRI2(7NE5., t ,,
Lawrence D. OPPer FROM TO DESCRIPTION S O
D
Well Contractor Name ft. ft
NC3322-A ft ft.
NC Well Contractor Certification Number
I'5;(1137ER-C lS1RG formlit casedssVetls OFEiNElt.tfia livable` ;,
,�-+m FROM TO DIAMETER. THICKNESS MATERIAL
Regional Probing Services ,, :e ft ft in.
Company Name _ FR
OM
oINJ g reial dosed loo -
A(��� 1 2�2Z DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 1ft '" sch 40 PVC
List all applicable well construction permits(i.e.County,State,Varian�t ft in3.Well Use(check well use): r,)`�tQJ6Water Supply Well: DIAMETER! SLOTS/ZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 22 ft 32 ft 0.75 1n. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft' ft in.
FROM p=
fBRt)ilTf ,.. r. 0` :
❑industrial/Commercial ❑Residential Water Supply(shared) TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Uri ation 0 ft. ft.
Non-Water Supply Well: 3 cement grout pour
OMonitoring ❑Recovery 3 ft- 20 ft bentonite pour
Injection Well: ft. f4
❑Aquifer Recharge ❑GroundwaterRemediation 9AIDIGRSi� 'AK if.a 'liabl
❑Aquifer Storage and Recovery ❑Sahnity Bettie[ FROM TO MATERIAL EMPLACEMENT METHOD
20 ft 32 ft. #2 sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
£�24
D1F1I4131IY
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/mck rain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 25 & Silty Sand
7/7/2022 Well ID=MW-12 MW-13 25 ft' 32 ft saphrolite/Weathered Rock
4.Date Well ,s)Completed: ft ft
5.Well Location: ft. ft
Former Sherwin Williams ft. ft
Facility/Owner Name Facility iD#(if applicable)
ft. ft
3125 Spring Garden Street, Greensboro ft. ft.
Physical Address,City,and Zip
Guilford
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification. Ld nCt° a��ura�v aM�w
(if well field,one latAong'is sufficient)
�ouoyz�a w,
'fin-, v�onaiwoa,re<°m.
36.06058203 N 36.0605820 W Opper � uo„b,,,,e,� siv2o22
Signature of Certified Well Contractor ' Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 2 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
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9.Total well depth below land surface: 32 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3 a200'and 2@100') construction to the following:
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10.Static water level below top of casing: a PP 27 (ft.) Division of Water Qua i lity,Information Processing Unit,
/fwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2.5 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
Geoprobe DPT above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
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(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Geothermal 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.
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Form GW-i North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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