GW1--06604_Well Construction - GW1_20231006

- -WELLS CONSTRUCTION RECORD. For[mental Use ONLY:
-Thb Cannon IJc•uscd for'single or iuillip)c was.
1.Well Contrite:0r Information: .
sf4:WATER ZONES'.• .:•I
Brian Ewing FROM , TO DICSGRIPTION'.
Well ConanaorNatne R. II'
4240-B fL ft, ( •
.
NCWcUCawaciarC6nifrcationNwdscT ;15.OUTERCASiNGtfar'aullt=caeed'iic11s1OR-LiNERlftup flcablel
FF1051 TO • DiAMETER THICILNESS \IATERTAL
SAEDACCO .ft. ft. 1n
Congruty Name" I6.1NNER'CASiNG ORTUBING(eoibermal ctaseddonj
DW08152023;202325-07-MW4 RWO;WM0401477 FROM TO DG►METER THICKNESS MATERIAL ' 4
2.%Vail Construction['e,mtt R: 0 ft. 10 ft, 2 ; `bI. SCH-40 PVC
litr iii!applicable we'll permit*,(1_e.Calmly..Vaac,Variarr .r,I#'a 8C4 sic.,' B. ft. "in. -
3.'Wclt Ilia(Cheri:Well use): 17:SCREJ:N - ' . '
�WaterSnpply well: — FRO51• .-I TO 'DrAMVTJ[R su:OTst'uY TntCl'4l.S 1 MATiSSAI.
DJAguculnlml C1MunicipaVFIEVIC 10 It. 20• ft. 2 •io 010 SCH-40 PVC ;.
©Geothemlal(EleatingfCooting Supply) ❑Residential Water Supply(siingle)•
rt. I ft in .
®Industdal/Conwtercial 17Rcsidential Water Supply(slated) 18cGRouT-_. ..- : ::y. . ...- - . _ - ..
FROh1 TO. ►1ATERIAI. EATPIACEMENT ME HOD&A\iOUNT
❑irrigation 0 ft, 6 ' ft.•• PORTLAND POURED
• NanrWatcr Supply WeU: •
R,• ft, I
IaMoniioring • DRecovery 1• ft
Injection Well:
°Aquifer-Recharge 1:7GmundtutcrRcntcdiation 19:SANINGRAVEL ACKtitulrrai leti)' - - -- - --_--- ---__- - -
FROM - 10 111,1110:M, •nh1P1.A(:}:V6,NTsoTHOR
OAaprifer Storage and Rccovrty OSalinity Barrier' 8 D, 20 ft.' FILTER SAND # 2
❑Agltitcr Tcsi OStotnns,tcr Diaiigngc •
.ft. ft.- • , . -
0EKpiriltictital Tecbuoto y IJSnbsidcrecc Control. •=20$DRiLL1irG'LOGYantiich'ridditionnl-sheMs if ncccssiiril- ,_ - --' .
• ❑Caeodtennnd(Closed Loop) ❑Tracer ' FRosi TO DESCRIPTION Rotor.Ius.tea,wn'nawk ltpc W*11i AM tie.)
• ❑Geothetnial(Reatine/CoollugReturn) . tOther(e!c plain under#2lRetuatks) 0 ' ft. 2 ft, Silty Clay- .
•2 ft. 20- , It. Clayey Silt '
4.Date,Well(y)Completed. 8-28-23 Net IDIIAMW=107 ---- -., —.-; ____;-
. • ft.' ft. . t 'C_..-_ r
Sa.Well,Location: • e.:.,_�:_.=1...:.t a�' a_.. ..
• ft ft.
OCT 0 '
City of Greensboro rt, ft.• U 20 2023
' Faaciility,Oisr rNainc Facilat)!IDh(ifapplicablcl • - --
ft. fl.. kUc:/r `;<,i :fir: z.7"?.; r'g i� ,
Right-of-Way near 2810 Stratford Dr., Greensboro, NC,. rt.. rt. G:`°i.~ '
27408 - - .Plo•sacnl'Address.City.aid Zip -.2f:REMASINS - -
Guilford• BENTONITE SEAL 6 TO 8'; -
County- Paiiel Ide)Iliti!hots No:(PIN)
5h.Latitude and[Angitude in dame s/minutes/seconds or decimal degrccs .,i CclTilic4thief: .
(ltuiit field,ofia Iattleng is-sufficient)
•
36.1126- N -79.8363 - �Q •; Brian, EVY,II, 9/19/2023
• 5lgtulura o!Cenificd Welt Cointmctor Date
6.Is(are)the.w'cil(y): �Petlitancnt or LITeulporarX Bh,signrng lldr foam.I hereby eerfife•rhraa:h1'•irell(N)rsys(rsrn)cortslnwiexl rn.rtuortlance
, 'wino 15d NCSC OW,dl0t7 Of 154 NCAC••it.0.02P0 Well Conslrracilar Stnrkiaals and;lira a
7.G:th[s a repair to an existint.writ: ' i7Yo or �No 'oprcf hir rrnt F lias lirra provided rn she hall imam
. If nuts is,a repair,fill eat{aiolnl acedconsrrafcaloa brforo*a:nn and caplaln the auaare of rhe-
reficiFerafiriJ21 irmarJ k.iraima or on the hark of thin fosse. 23.Site diagram or additional well details:
•You may use the back of!tits-page to provide additional well site derails or welt
S.Numberof welts canstn acted: 1 cousttuction details: You.niay alsi:ittach additional pates if necessary.
Foranaalalple Ja0'ecrlon or orxn-nate'r supply wills ONLY.i 1rh rha'snoe eans►rurtioar,}'oa cons .
.s-abnrirone'jorm. - - SUBINITTAG iNSTUCTIONS
9.Total well delith 6etew and surface. 20 (ft) 24a. Far All Wells:, Sabath this forth williitt 3U days of comptedon-of well
Far nrnlriplcn•clls.70tnlla'eprhstfd4ft?renr(rmrlaple.3@@200'and 2@/ ) constntctiontothefollowings;. ,
• 10.Static water level below fop of costa);: 12.86 (11,)' Diviviniu'tf Water Resnu rear,Information Processing Unit, •
If un;er level!r share rosiaag;use"+" - -- 1617 Mail Scn ice Center,.Ralcigh,NC 27699-1617
11. orehotediameter:8.25" (in.) 2a1l.For In Notion Wetly ONLY i ; in addition to.sending the form to tine add r ss-in
24a above. also submit a copy of tills fonu within 30 hays of completion of well
12.Well constrttetinat method; ESA & Direct Push c nstruction to the following:
(i-c:3ugcr..,tmtaiy,cable direct.push.etc.) • -
Divisiou of Water Resources,Underground Injection Contra Program,
FOR WATER SUPPLY WELLS ONLY:' 11636 Mail Service Itdttler,Raleigh,NC 27699-1636 •
13a1 Yield(gym) Method of Last: 24e,For.�Water Supply&_inicction Yells:
Also submit one copy of this font t within 30 days of completion of
13b.Disinfection type: . • Amount: well construction to the county health department of the county where •
constructed.
Fonn,GW-t Noah Carolina Dcpannienr of Environment and Natural Resources-D_ivislon of Walei-R* ,otrorl Revised August 2013
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