GW1-2022-08538_Well Construction - GW1_20220502

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
14:.R TEWDA99
Lawrence D. Opper
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A
NC Well Contractor Certification Number 15:OU7ER CASiN •for multi rased.ve113 OR L7ER if a 'livable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name 16:1NNER CASING OR TUBLNG edthermal closed loo
FROM TO DIAMETER THICKNESS .._MATERIAL
2.Well Construction Permit#: 0 ft' 3 ft. 2 i" sch 40 PVC
List all applicable well c:onstruclion pennits(i.e.C'oun$t State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 ft 13 f` 2 in' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R. i"•
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&A-MOUNT
❑Irrigation 0 rr. 1 ft• cement grout pour
Non-Water Supply Well:
I7Monitoring ❑Recovery 1 tt. 2 ft- bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation Y9:SA�DIGRAt£> PACK if�a licabte�
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 f`• 13 f`• #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
fr. ft.
❑Experimental Technology ❑Subsidence Control 20;BRILLING;3�OG'aNachudditioiial sheets if necessary ,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rL 13 ft• silty sand over silty clay
4.Date Well(s)Completed: 3/8/2022 T-MW-9 rt. fr. A p— -a
5.Well Location:
A Cleaner City/Tops Cleaners DSCA DC410023/DC410051 tt. ft. MAY 2 207-9
ft. ft.
Facility/Owner Name Facility ID4(if applicable) ft. ft. •. I SG
2804 Battleground Avenue ft. fr. yrit ',UNF
Physical Address,City,and Z _
"IL REMARKS,`—,
._....
Greensboro
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification
(ifwell field,one ladlong is sufficient) yua ysiyoedby awre opper
36.106129 N 79.832961 w pp oN:n=aw enee0pper.�aegfunai
Lawrence O 2 `'Probi^95ervi«:o�• 3/22/22
riiail_larry�aregio�lprobing.mm,c=US
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby:certify that the well(s)wzu(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 62C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KINo copy ofthis record has been provided kn the well owner.
If this is a repair,fill out known well construction into and explain the nature of the
repair under 1121 remarks section or an the hack of 1his firm. 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.
For multiple injection or non-water supply wells ONLY with the salne construction,you can
submit one Tarn,. 24.Submittal Instructions:
9.Total well depth below land surface: 13 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd ereni(example-3@200'and 2@100) construction to the follovt7ng:
10.Static water level below top of casing: approX 10 (ft) Division of Water Quality,Information Processing Unit,
1/'water lei-el is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 4.5 (in.) 24b.For Injection Wells: In 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 Ceni cr,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
136.Disinfection type: Amount completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quaf4lity Revised Jan.2013
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