GW1-2022-08480_Well Construction - GW1_20220502

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. O er 14.WATER ZONES
pp FROM TO DESCRIPTION
Well Contractor Name
NC3322-A
NC Well Contractor Certification Number 15.OUTER CASING,formniti-cased wells OR.LiNER if a"licable
FROM TO DIAMETERi THICKNESS MATERIAL
Regional Probing Services ft. ft. 'in.
Company Name 16 INNER CASING OR TUBLNG(geothermal closed-loop),
FROM TO DIAMETER'. THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 8 ft. 2 sch 40 PVC
List all applicable well construction permits(i.e.C'omtry,State,Variance,etc.)
ft. ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DtAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8 f`' 23 ft' 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) rt. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18rGROUT
FROM TO MATERIAL EMPLACEMENT METHOD&A-MOUNT
❑Irri ation 0 ft. 3 rt. cement grout pour
Non-Water Supply Well:
ZMonitoring ❑Recovery 3 7 rt bentonitei pour
Injection Well: rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.`SAND/GRAVEL PACK ;f:a licable : m
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 7 ft' 23 f`' #2 sand Prepack/pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG`attach additional aheets if'necessary :
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,witfrock tv e,gritin sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 23 rt silty sand over saphrolite
4.Date Well(s)Completed:
3/8/2022 T-MW-10 ft. f`'
rt. ft.
5.Well Location: ft. rt. P,
A Cleaner City/Tops Cleaners DSCA DC410023/DC410051
ft. ft. 9
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2804 Battleground Avenue
Physical Address.City,and Zip 21,REMARKS
Greensboro 14A J
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient) oy si ed by Lawrence Opper
ON:c lawrencc Opper,o=aegional
36.105968 N 79.831533 W LawrenceOpper`e`ma;°ae9;oaiprpbing.mm,c=u5 3/22/22
Signature of Certified WellContractor Date
6.is(are)the well(s): [i7Permanent or ❑Temporary by signing this form,1 hereby certify that the tte/1(s)was(were)constructed in accordance
with 15A NC4C 02C.0100 or 15A NC9C 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy ofthis record has been provided to the well owner.
I f this is o repair,fill out known cell construction information and explain the.nature of the
repair under 1121 remarks section or on the back of dds 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: 1 construction details. You may also attach additional pages if necessary.
!or multiple injection or non-water supple wells ONLY with the same construction,yen can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 23 (ft.) 24a. For All Wells: Submit this fomi within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: approX 18 (ft) Division of Water Quality,Information Processing Unit,
?/'water level is above casing.use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 4.5 (in.) 24b.For infection Wells: m addition to sending the form to the address in 24a
Auger above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(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 fonn within 30 days of
13b.Disinfection type: Amount: _ completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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