GW1--06600_Well Construction - GW1_20231006

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WELL-CONSTRUCTION RECORD For[mental Use ONLY: j .
This form can t ii cd for single of multiple wells ,
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1.WellConurtctorInformation: , , '
;tJ WATER ZONES' •.
Brian Ewing FROS'. ' TO - DESCRIPTION
Wc11 Carilraiortfame ft; R. f
4240-B fit. IL
NC Well CantraiiarCcpiftcntionNumb 'A5.OUTER CASING(fornrahi-ra9editelis)"ORi.INERf1Tup Ilcabk),
.FROM To D AMETER- THICKNESS MATERIAL.
SAEDACCO I.!. . .ft.. .in. .
Company Name I6:'INNER CASING OR UB INGlieelberznat cluscddonj,),..'
-EROS! 10 ' DIAMETER THICKNESS MATERIAL
:.WctlConstnietionPs,mit#: 2023-25-07-MW4-RWO;. WM0401478. 0 ft. 15 ft, 2 '-'nl. SCH-40 PVC "
Lift idtappGrobre KritOrrraitr(hr.Coiody.-Srarr.4rtrianee.1r feetiGn;e1e.)•
it. - ff. 41. -
3. .Cil i55e(vIi Uliii'di p4C)1 f7 SCREEN •
Water Supply Well:` — -. —_.. -_ - " - FROM '- TO -DIAMETER SLOT SIM _I T1IICKNfitis' t MATERIAL. •
CItlglicill[utal, -DMunieipal/Pttb)ic. 15 fit. 35' ft. 2 in. OSO SCH-40 PVC
I Geothermal(IieafinglCoolingsupply}: ❑Resiidential Water Supply(single) . II'. I fL in
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•i IJndustrial/Confmcrcial , G)Residential Water Supply(shared) to TROUT:-- :. -.- . ,.„
FROM TO MATERIAL ' ENIP1ACEMGNT METHOD&Ah OONT
.f❑IrrigitIeon - . - - . 0- it. -11 ft PORTLAND POURED ••
Novi-Water Supply'Welt:.
R.: ft,
®hloniioring .. I:Recovery . - .
Injection Well: !4 It. .
0At(uifer-Rcchargc ElGiotlndn;ttcr Rentcdialioa 19:`SANDIGRAVRL-PACKlir unlilicyble)<:-; _ • -__-_.- -_ _- — - _
FROM- TO - MATERIAL ESIPLA:E1IENT MITROII '
ElArjuifcr Stange and Recovery ElSalinily Barrier". 13 ft. 35 iL' FILTER SAND # 2
❑AStltifcr.Tcst- EISIOMmaterOrltinge .
'ft. ft.
E'q cr%mcntel Tecbiitild "❑Suhsidcncc Conitel❑ .
Ao:DRILLING LOG"fiilfacli nddiliennl'slieetilf-iiccessnrti) -- - _
❑Geothential(ClosedLoop) OTracer - FROM - TO DESCRIPTION(cobr.linrdncn,will/rock Om.grain sne.de.1
' • ❑Geothermal(leatinUCoollug Return) ❑Other(e:Xpleiii Maier in t Reivaths) 0 rt. 4 ft., Clay' •
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4 •ft, 35 ft Silt • . . . .
4.Date Well()Completed: 8-30-23 -Well mkt AMW-105 fit. ft..
•5a,Well Location: ' . . L - v./ r n
r"rye.
Battleground Kia . - ft, ft, - ""
Faciity,OwnerName FecOrt1 1Dk(ifapplicablc) - - - - 0 /emu
2927 Battleground Ave., Greensboro, NC, 27408 - ff., tl.
Plosieter.Aidress.•City.and Zip '4I:RENIAl`tk$ 01,`;. 7L1
Guilford BENTONITE SEAL 11 TO 13'
County Intel Irks liflOnioe No.(PIN) -
Sb,Latitude end Longitude in flcr reeStminutcslsccondsor.dccimiil degrees: n.Cct7ifcadon: '
(Itwell rrekti oue-IttPlen lj Snrtieletu)
36.1127 N -79.8353 •fir Brian Ewing 9/19/2023
Signature ofCertiGed Well Centmata ' Datc
6.Is(are)We:well(s): 10Penuanent or iTemporaiy
rh•.signing drir fOrro,f lrereby crrlifr,rLig 44 u•ell(s)war(Wrfe), x airnr red Dr accondmu'e
mrra ISANGICO2C.0100or1SANCriCOW.0200 Well C'o rueilartSrandardsToedtheira
7.is:thbi a repair to an,existing well: ❑Yew or IONo• copy of rrus recoiYIItrsbeen proridiV ro a e 4iyrli mvner.
Yetis*d repair,fill oot.kfidien*ell constraierion biforinarlon oral explobt the-nornre of the !- '
reparrrriuler#2l irnu e:A-irethon or;An the baeioFt iifor . 23.Site dial;ram or additional.l4,elldetails: ' •
You.May use the back'of this page to provide additional well site details or Well
S.11umberof wells constructed: 1 - construction deiaits: You.ntay alto:Mach additional pages if necessary.
For ritaildple lojeerlon or ao i-yorer supply wells ONLY wit/i the same conarruetion,you coo '
sabotiroae form. • - SUBMITTAL iNSTUCTIONS •
9.Total well depth betinv lead surface:- ,39 (fit.) 24a. Far-All Wells: Submit this f&m Within 30 days of completion of Well
For uunhiple µ ells liit off4eprbs Ifdi/Ji'rens(ample-3€2O0'emu/2@100)' .construction to the roaming:. 1,
10.Static water level below top of easing: 2 5.3 5 (R,) - Division of Water Resources,Infirrmation Processing Unit, •
if MIN t kid Is above cvrsiag;ore"+" • 1617 Mail Service tcntcrt.Ralcigh,NC 27699-I617
II.Borehole diameter:8.25" . (in.) 2411.For Infection Welts ONLY:In addition to sending the form to the address in
24aaboVe. also submit a copv'of this fine within 3o days of completion of well
_ 12,Well constntction method:HSA & Direct Push • construction to ibe following:
(i.e.pugc-jog:ry.cable.direct.pirst.etc.}• - - - i
Dlyisiou of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY;". .1636 Mail Service;Center,Raleigh,NC 27699-I636
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13a Yield(gym) Method of test: •
2.Ic.For Water Supply&injection Wells:
Also submit one copy of this form within 30 days Of completion of
13b.Disinfection type: Amuuat: • _- well-construction to the county health department of the county.where
' constricted 1
Fenn GW-t N-onh Carolina Department of Entitniilmin and Narural Resources—Dh''hlon ofWalerRrsotrroeS Revised August 2013