WM0401449_Well Construction Record(s) (GW-1)_20231006

WELL CONSTRUCTION RECORD (GW-1)
Print Form
For Internal Use
1. Well Contractor Information:
Daniel Summers
Well Contractor Name
2579-A
NC Well Contractor Certification Number
Carolina Soil Investigations, LLC
Company Name
NCDEQ: WM0401449 / Guilford: 2023-01-20-MW9-RWO
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
0 Agricultural ❑ Municipal/Public
0 Geothermal (Heating/Cooling Supply) ❑ Residential Water Supply (single)
0 Industrial/Commercial ❑ Residential Water Supply (shared)
❑ Irrigation ❑ Wells > 100,000 GPD
Non -Water Supply Well:
® Monitoring 0 Recovery
ection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling
❑ Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑ Other (exnlam under #21 1
4. Date Well(s) Completed: 09-05-23 Well ID# MW-2 MW-3 MW-4
5a. Well Location:
Former Lee Mart #2
Facility/Owner Name Facility ID# (ifapplicable)
1614 West Friendly Ave Greensboro, NC
Physical Address, City, and Zip
Guilford
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.07557 N-79.81464 W
6. Is(are) the well(s):® Permanent or 0 Temporary
7. Is this a repair to an existing well: 0 Yes or ® No
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 form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 3
9. Total well depth below land surface: 3@25 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing: 14
If water level is above casing, use "+"
11. Borehole diameter: $n (in.)
12. Well construction method: _
(i.e. auger, rotary, cable, direct push, etc.)
auger
14. WATER ZONES
FROM
TO
DESCRIPTION
10 rt.
25 rt.
et.
rt.
15. OUTER CASING for molt' -cased wells OR LINER if a licable
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
10 ft.
2 in
sch 40
pvc
16. INNER CASING OR TUBING(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
rt
rt
in.
ft,
rt.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
10 rt.
25 ft•
2 in.
010
sch 40
pvc
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 rt.
5 ft.
portland
mix & Pour
5 ft-
8 ft.
bentonite
tremie
rt.
rt.
19. SAND/GRAVEL PACK if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
8 rL
25 ft.
10/30 silica sand
tremie
et.
rt.
20. DRILLING LOG attach additional sheets if necessary)
FROM
TO
DESCRIPTION color, hardness, soil/rock type, grain size, etc.
0 rt•
25 ft•
brown silt loam / brown silty clay / saprolite
fr.
rt.
fr.
rt.
et.
rL
ft.
rL
21. REMARKS
22. Certification: n (,- 1,,- 09-05-2023
Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
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 Water Sulply & Injection Wells: Iniection Wells: In addition to sending the form to
the address(es) above, also submit 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.
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018