GW1--03052_Well Construction - GW1_20230310

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14:WATER ZONES
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. &
NC Well Contractor Certification Number 15 OUTER:CASING'for multi=cased wells OR LINER if a licable .
FROM TO DIAM1tETER THICKNESS MATERIAL
Regional Probing Services ft. fL in.
Company Name `16.INNER CASING OR TUBING eothermal closed=loo
Guilford 2023-02-06-MW-4-RWO FROM I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 6 ft' 1 i" sch 40 PVC
List all applicable well construction permits(i.e.County,State,variance,etc)
ft. ft. in.
3.Well Use check well use):
( 17.-SCREEN „ r:
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 6 ft. 16 ff 1 '"' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft. cement grout pour
Non-Water Supply Well:
i 3 ft. 5 ft- bentonite pour
17Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
5 ft• 16 ft. #2 sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
;'20.DRILLING LOG(attach additional"sheets
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,grain sire,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 16 ft. Silty Sand over saphrolite
4.Date Well(s)Completed: 2/9/2023 MW-3 ft- 16 ft. Bedrock Refusal
ft. ft.
-
5.Well Location: ft. ft
Culp, Inc. ft. ft.
Facility/Owner Name Facility lD#(ifapplicable) ft ft MAR 2 n 20
70
1150 Silver Court, High Point ft. ft.
Physical Address,City,and Zip t 1
��2'1.!REMARKS""
Guilford
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: u9mu,�Wenroovtt
(ifwell field,one lat/long is sufficient) aw Ce 1i D"'°F�'""1Ceo­ Reg'owl
35.9248592 80.002648 O er9=eM
,�,m����aa�<�. 3/2/2023
pp r � r�rrd3�r,6.,so-0=
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an.existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this farm. 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 multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. 24.Submittal Instructions:
9.Total well depth below land surface: 16 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ii different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2.5 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Geoprobe DPT 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SuDDIv&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-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013