GW1-2022-08574_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR WATER ZONES.
Well Contractor Name FROM TO DESCRIPTIONy
A - 3098 'L G E it V E D ft. %
NC Well Contractor Certification Number '15:OUTER CA,SING for multi-cased iwells OR LINER if a licable
GEOLOGIC EXPLORATION MAY 3 0 2022 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name ,•
Iftipf71i1.7 I'i:1i:�i.3>l:r(� Una 16.INNER CASING ORTUBING eothermalclosed-loo
2.Well Construction Permit#: ta'Q/130G FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) 0.0 ft. 10.0 ft. 4.0 1°' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: A7.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 It. 25.0 It. 4.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT.
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIALLY EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 6.0 It. PORTLANDBENTONRE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 8.0 It- 25.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) itOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain sire,etc.
0.0 It- 0.5 f` CONCRETE
4.Date Well(s)Completed: 04/12/22 well ID# SVE-2 0.5 ft. 1.0 It- GRAVEL
5a.Well Location: 1.0 It• 22.0 It- RED/ORANGE CLAY
BILL MARION 22.0 It- 25.0 ft- BROWN SILTY CLAY
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4557 PLEASANT GARDEN ROAD GREENSBORO 27406 ft. ft.
Physical Address,City,and Zip fr. ft.
GUILFORD 21.REMARKS.
County Parcel Identification No.(PIN) BENTONIfE SEAL-6.0-8.0 FEET
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***SOIL VAPOR EXTRACTION***
(if well field,one lat/long is sufficient) 22.Certification:
350 58' 19.01" N 790 45' 56.45" W � 04/25/22
6.Is(are)the well(s): POPermanent or ❑Temporary 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 MNo 15A 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 ofthe ofthis record has been provided to the well owner.
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: 25.0 (ft.)
For multiple wells list all depths ifeli erent(example-3@ 200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifrvater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 10.0 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018