GW1--05746_Well Construction - GW1_20230905

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WELL.CONS.TRUCTIONRECORD Fgr tactual Use ONLY:
' ' nip.form cun,Wiwi fai.tingleormultiplewcIIs• - -
1.Wcit.Contr.•tetoirInfornfatiau: .
1.LWATERZONIS, / ... - . . - .
Stefan Smith ROM. 'iit DFSt:'Rrl*r14N
W eil Ctilitr ctor Name. R. it.
3576-A •
ft. it:
NCWcIIContraciorCenifinetioaNumber E5:"OfiTERCASNG`(rnriiiulficavelfricRslOttLrNERilfisp tleabkl'
FROM' TO n AMETEtt: THICKNESS ' - ',MURLtt.
SAEDACCO f4 . fL • P I la.
Com�tartyhamq t6:INNER CASING'OR.TUBING{yeut6ermal'cla it.1i4 ,
FROM 'TO - DL MMETER TIIICKN£SSs.MMATtR)AL
2.WclUConatruciinn Pe,ruit t: • 0 'R., 10 it. 1 j' .I SCR-40 PVC
Liti XI applicable 41..11 pr-1mks(ie.,County,:Stu:e..Yariance.frl$1ral err l
ft.: it. ;i :it. .
3,'Wrlt tJsc(chccLrvcli use):' • Alt-SCREEN . .
• Water Supply,%ill:' 'moat TO arAMFTER °srorSln: THICKNESS 1 y1ATrarat, .
10 'ft. 20 `t. 1 •n(l,. '.010 SCH-40 PVC
trl •
gticulto[al. tJMiinicipaliPublic, 4
I Geolhetmat(Heating/Cooling Stiihply) ®Residential•W'lter Supply{single) if' it: io
©[tidustrial(Conwlcrcial - tjRcsideutialWater-Supply(skated) ;18eGROUT ._ _._ ,, ._ . _.. . ._ _
FROat. TD. i MATERIAL I EMPLACEMENT MEi11OD S AMOUNT
❑lrripation .. . . . . at.. tt
• Nou-W.itcr Su piq Well: -- ..
59Manitortng • 1311ccoviry ft.. p.
talent tun Welt: it. . ft..
IDAgttifcrReciiarge ClOiauidttalcrRentcdiatiau 415:SAND/GR,tVNLPACE ir.attdtcaotel•' . = =
'•FROa1 TO' ` aIATP.RttL EaiPLtC1MENTalmelon
I3r1nitifer,Sloragc at.Rceovcy IJSalinity Hamer . . .ft,. ft. ,
ElAnnit.rTcst• OStorlriitatcePutt rIgC 1:
. .
ft.. - •ft. .
C]>:ipctinicitial Ttxlmalo f]5nbsidcttcc.(oalml :n DRILLING LOG(riltach addlhaait sheers if ncctcca�) '
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OGeothennul(ClosedLoop) . ❑Tracer . . FROM 70 DF.SCF.rPTit3N(wbr.>,aritnca.erlL'nxkt�nc:ordn uaetal
t7Geotliennal(HeatitiefCoolingRetuit) ElOther fespliiu under.S2I Retuati;sl .ft. f4 ,
it. i6 i
i.DateWelC(s)Completcd: e/16f23 WcIIID#$-g ft; • ft. i' - . 't�i 1lA
-,r. ,r L._.1 0__
5a:`vim Llicationt .iL- ft, '
Forest Oaks Circle K f4 ft'' S E P 0-5 2023
facility/OisnerNurne Facliiy1Dk6fa144cable)., •r.t - .
5324 Liberty Rd., Greensboro; NC, 27406 - - R•- . ft. Irlfar4Tri3acrl i�f,''CStS 2Ss'a>iJ(ate
•ft. ft. 't�
Pliysiead Addrsss.City.;tnd Zip ' 3it RUIIiAt '• .• ' '
Guilford Temporary well for grab-sample - '
County Par>:d kketittc:aionNo;(VW)
Sii,.J-ittitudc'anif LongIttnlein ite rccs/tniitutcs&sccondsOr decimal degrees: 22:.Cct•riticahoa: '
(lr.►gin raid;u 1a+7oli ix slrirci<»}
N W .•.„ •/ � I; 8/24/2023
Signat•�ofCc.tiedWOCaniraetor.• Dafe
6.18(.rrc)tke:nelI(s)i UPl'171fanent or iTefnporat}' signing. this im;.l herrb certi vfl ur Mr iidifi l V.u.Y berm)raa_rlrucferi irt;rctonirncr
�F Jb 3' f:.1
••i{'ilh15.tNCACO2C.01(s'.)or1,tNCACO2C:020i>WellcettrtrorriniSraodardsand:1a a
1Isthisareirairloatieiiiitingwell: ❑Ycr•' or ®No 'iopiirofthkrrerini big:lmen(i.rnriiledto•ihe-inllii+riter.
ffrh lilt a o pals,fill our knrii}w well tOtwA(Cl/at1 htlaras UIon moll c.gi(oin rhC Aorore of the ,I'
re}raircarder021_rrmarks:;rrivauoristhe hat ofdtisfor,i . -23.Site dingram•or.additional.ttie(ildetails:
You tnay:use llye.bacl;of this page to ptoyide'.idiilionat well site details;or well
B.ISumberof Wells'constructed: 1 -cousiiucttonf derails. You inay a lsa•aita'eh:idditional pages if necessary:
For lnnlrlple hfecrio,i orrn i-BYRer supply wells ONLY with rhu.saeleconstrticliwr,you 0011 -
A-Oink aae form. SIiBMJTTAL iNSTUCTIONS
9:Total well depth betoiv•land surface: 20 • ((L) 211 For Alt Wells Subiitit this'fortn within 30 days of coniptetiou`of well
For ircutripleivrllslist ail diprhsifdtffrrrnr(crarnpla-30200'and.2(0100f) - ' ' -constnictiontotitefotloniug: i ' .
10.Static water level below.top of easing - . ((I.) . Divisiiin of Witter R�spurces,Information Pivee�sstng Unit,'
if m ar',lei'el'ls above cd5f14,are"+" - - 1617 lifail.Seriiceiccnter,Raleigh,NC 27699-1617 ' -
Ft.Borehole diameter:2.25". - - '(in.) .24b;For injgctton Welts ONLY: sin addition to-sending the fomr to ilia address in
24aaboi'e,also subsoil a.copy of this.fonit triikuf 30 days'of completion of well
12..'Wcllconstruction method:DPT . . cousiruclimt to•tlie follodine:: 1
(i.e.auger,rotary.cable;,direct push.etc.} t
Divisfait of Water ResoureesOndergrouted ftijeerlen Control Prugrant,
FOR WATER SUPPLY WELLS ONLY:- 1636 Mail Service'C nter,Raleigh,NC276994636
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13:t,Vicld(dim) \fetltod of test: 24e..For Water Supply.&Injcetion.Welts:
Also subunit one•copy of this Tanu Within O days of completion of
131i.-Disinfection Ante: • Amount: well:cgnslnictien to the county health depariment ofcounty the where-
conistwatcd.
• Form GW-I North Carolina Department of Err itotwr_lu and iJitural Rcmurecs-Division of Water.R ath Reiised-August 1013