GW1-2023-02965_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This rorm can be used for single or multiple wells
1.Well Contractor information:
Lewis Lefever 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name f[. ft.
2480 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for muIn-cased wells OR LINER if a licable
FROM TO DIADFETEil THICKNESS DiATER1AL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft. 2 in- SCh40 PVC
List all applicable well permits(i.e.County,Stale,flariance,I jection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public- 10 ft' 25 ft- 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Su Iv sln le ft. ft. in,
PP Y) PP ( g )
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 fr.- 8.5 et. Portland Cem Tremie
-- -- r on Water Sti piy W_e1 - - ---- - -- - -- - --- - - ---. - - - - - - - - --
❑+Monitoring ❑ ry Recove
8.5 It. 13 ft Bentonite Chil Tremie
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 13 fr' 25 ft• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,emin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
rt. rt.
_
4.Date Well 4-6-23 MW-19R s)Completed: Well ID# ft _ f }
fr. . 'aw. N -1%iPi
5a.Well Location: ft. ft. 'p r
Duke Energy ft. ft. ❑D 2 5 ZUB
Facility/Owner Name Facility iD#(if applicable) ft. ft. APR
321.E Friendly Avenue, Greensboro -- - �r'
fr. ft. '
Physical Address,City,and Zip
21.REMARKS
Guilford J Plug
County Parcel identification No.(PiN) Bottom Cap
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one latilong is sufficient)
36.074718 -79.785503 N wx,.f
sigiAturc of Certified Well IntracYor Date
6.is(are)the well(s): [OPermanent or ❑Temporary
By signing this form,I hereby cerrifb that the well(,)was(were)constructed in accordance
wilh 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consiruciion Stnndorth and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy oflhisrecord has been provided to the well owner.
If this is a repair,fill out known well construction hijbrntation and explain the nature of the
repair under=21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For ntalliple it jection or non-water stfpp/v wells ONI.Y with the sane construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nnuhiple wells list all depths ifdiffereni(example-3It 200'and 2@100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
Iflrater ievel is above casing,use"- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For iniection Wells ONLY: In addition to sending the form to the address in
HSA/spoons 24a above. also submit a copy of this form Nithin 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 Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:
24c.For Water Supply&injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: 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 Resources Revised August 201?