GW1-2023-01872_Well Construction - GW1_20230222

I Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
� i
1.Well Contractor Information:
i
Virgil Wilson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4473 16.5 ft- 27.0 ft- wet
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable)
Parratt-Wolff, Inc. FROM TO DIAMETER THICI4�lES5I MATERIAL
ft. fr. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loo )
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) 0 ft- 17.0 ft. 2.0 '"' SCh.40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 17.0 ft. 27.0 1" 2.0 '"' .01" Sch.40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. g, in,
Industrial/Commercial E3Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 13.0 ft- Port./Bentonite Tremied
X Monitoring Recovery 13.0 ft. 15.0 rt• Bentonite Poured (chips)
Injection Well:
fa ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(ifa licable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 15.0 ft. 27.0 ft- #1 sand Poured
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION(color•hardness,soiltrock type,Brain size,etc.)
0 B- 3.0 ft- Asphalt/Concrete
4.Date Well(s)Completed:12/20/22 Well ID#�W-1 3.0 It- 10.0 ft' Fine'sand with silt
5a.Well Location: 10.0 ft• 11.0 ft. Fine sand F-_ �- - -
T-Force 11.0 ft- 27.0 ft. Unsorted sarid_Z r' 0
Facility/Owner Name Facility ID#(if applicable) ft ft.
4411 Groometown Road, Greensboro, NC 27404 fL ft. v Z3
Physical Address,City,and Zip fL ft.
Guilford 7841488573 21.REMARKS
County Parcel Identification No.(PIN) 8"flush mounted cover installed in a 2' concrete pad
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C rtification:
35.995601 N -79.863089 W
1/10/22
Temporary Signature ofCertified Well Contractor . Date
6.Is(are)the well(s) X Permanent or
By sign g this form,I hereby certify that the svell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or X)No with 15A NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain lire nature of lire copy ofdiis 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 site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:One
SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 27.0 ft.
P ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple weds list all depths ifdifferenu(example-3 a 200'and 2 tt 100') construction to the following:
10.Static water level below top of casing: 16.5 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8•0 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
Hollow Stem Auger above,also submit one copy of this)form within 30 days of completion of well
.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service' l e ter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, also subniitl 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.
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I I