GW1-2023-00781_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
DAVID HALL 14.WATERZONES t
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4459 ft. fr. F 1 1
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased s'vells OR LINER if a )licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
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.U1C,County,State,Variance,etc.) 0.0 ft. 55.0 ft, 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft. 15.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 10QQ00.QP9^".,q f FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: l� his 5 r1 k-1;Yh 0.0 ft. 3.0 ft. PORTLANDBENTONRE SLURRY
��,,4�„ awe''
INMonitoring ❑Recovery
Injection Well: AN A a ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
-n ;,rOI)fc19.SAND/G RAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salim�'B�[C1C !-n FROM TO MATERIAL EMPLACEMENT METHOU
'�j{.e q r�.�ICi�L7
❑Aquifer Test ❑Stormwater DraiKaie 4.0 ft- 15.0 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) ❑Other(explain under#21 Remarks) FROM I To DESCRIPTION color,hahriness,soil/rock type,grain size,etc.
0.0 ft. 0.5 tt• ASPHALT
4.Date Well(s)Completed: 09/15/22 Well ID# MW-1 0.5 ft- 1.0 ft. GRAVEL
5a.Well Location: 1.0 fL 15.0 ft. SILT
CIRCLE K - 2723476 ft: ft.
Facility/Owner Name Facility ID#(if applicable)
fr. ft.
3302 SOUTH HOLDEN ROAD GREENSBORO 27407 ft. fr.
Physical Address,City,and Zip ft. ft.
GUILFORD 21.REMARKS
Comity Parcel Identification No.(PIN) BENTONITE SEAL-3.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
360 01' 09.58" N 790 50' 47.09" W /fi e
09/21/22
6.Is(are)the well(s)• INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,]hereby certify that the ire//(s)was(were)constructed in acc'ordmhce with
7.Is this a repair to an existing well: OYes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1J'Ilds is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under'21 remarks section or on the back ofthis 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 i 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: 15.0 (ft.)
For multiple wells list al/depths ifdiJjerent(example-3 rt 200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
8•0 24a. For All Wells: Original forth to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/fwater level is abore casing,use +"
11.Borehole diameter: 8 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
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
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