GW1--06640_Well Construction - GW1_20231006

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WELL.CONS` RUCTION RECORD •
For[Mental uscClNLV: I ;
This form can be•uscd for single or multipk wells• f
1.Well Couttactor Information: .
:',14::WATERZONGS' _ .-
Brian Ewing • FROM. ' 10 DESCRIPTION
Well CaniradorName R. ft,
4240-B It. rt. J
NC Well Conllarlor Certification Ntmitlet •`IS OUTER CASING(for tulti-craeJtictisl OR LiNER Man ticablel: .
FROM TO DIAMETER• THICKNtESS MATERIAL
SAEDACCO tL ft. I' '.in..
Company Name' 16 INNER'CASiNG OR•TUBING ljoilsermat ctu td-Ioep}: '
FROM 10 _DIMiETER. THICKNESS MATERIAL _
2.well COnstruetinn Fern*ff: DW08152023;2023 25 07-MW4 RWO;VMA0401477 0 R. 20 It. 2 • ' in. 'SCt3=40 PVC
. Liiral)npplirable well ficrmlts(i.e.'county.Saae.Variance.Ile q-rt !• -
ft, ft, in.
3.Well 13se(cltcelcirel1 use): ,27:SCREEN
•
Water Supply Well:' FROM• 1 TO DMAIETER 54(yTsin I T11TCt4Vr s 11IIATFRIAI,
• CJAg.Ticullutit. ElIcliInlcipal/Pulllic 20 ft. 35 R. 2 •• 030 SCH-40 .. PVC
©Geothermal(HeatinglCooliug Supply) ❑Residential Water Supply(sir gle)• fi. rL in,
®Industrial/Coutntarcial ®Residential Water Supply(shared) T9 GROtfT: . _. ` __. .: :
FR051' TO. ' • MATERIAL E'NIPLAC'ENEVT.:MEM-10D C Ab101TNiT
. ❑ltri@ation - • . 0 ft. 16 . ft PO_RTLAND POURED
Non-AVater Supply Welt: rt
Monitoring . °Reco►ety . - •
injection Well:- . - .ft. , ft.• ' •
°Aquifer-Recharge °Groundwater Rentcdiation ,t9 SAND)GMVEL-rACi{:tir-appucabtrl4 - -- ------- - -=-_. - -.- -
FROM in MATERLU; KMPI.,i.(:1:11rNT M1a•IIOrr
IDAgitifcr.Storigc mkt Recovery °Salinity Barrier. 18 ft. '35 , ' ft, FILTER'SAND # 2
ID Aquifer Test- l7SO:mos-Met Di:tinogc .ft. ft.
❑1~*ctiinenlal Tc linolog)' ❑SIt115idertcc Control.
-20;DRILLING'LOG7iitlaeli uddiiiouaisliceld•ifkiecessar0 -:
❑Geotllentztl(closed Loop) DTr.Icer FROM TO DESCRIPTiON Ram.tianlncii,xdknickir pt.min cim.Nt.!
❑Geodteniial t•Aeatine/Cooliti Retuni) ,'❑Other(elcplaitt wider#21 Remarks) 0 IL 35 ft silt
ft. • ft.
4.Date%ll(s)Completed: 8-28-23 Well IDf/ANN-106
tl. tL .
5a.Wc1I Location: ft. tL -.::< '�. :Y rot"'E.'"
City of Greensboro tt, ` • it.
Facilitp;QlsnirNtiruc FacilhllD (ffapplicible) R. R. - _ U1. I (J V [ll
Right-of-Way near 2737 Stratford Dr., ,Greensboro, NC,, , h , . • ft. .
27408 • Pltysical'Addrsss City. Zip ;2t:REMAliS in_cri3r.;,..n arc:^$,1, a:2 1..ln'f
R ;:,%M.i`1
Guilford • BENTONITE SEAL 16 TO 18'
•
t:onaly 1'areei lacsliti boil No;(PIN) • . • i . .
Sb..Latitude and i ongitude in de grceslminutcslsceonds ter decimal degrees •22.Ccititirutltia:
(If>,ielt!'reed;lute-lauiloug ts-sttfiiciept)
36.1118 . ly -79.8355• . ' W Brian Ewing_ 9/19/2023 .
Sigmlt5e01 Certified Well Coiitm;tar j Date
. 6.Is(are)the.well((): 10Peniiauent or. .OTetigwrary. . I
By Afgning thin jinni,l hereby ceifift•rhos the orell(s)n71r f wrnyl coratrialed ire aaortlanee
win)Mt NOW02C•0100 or I5 t NCAC lr2C.0200 Well Cwisrrrwrlotr'SrardardsWire rlrrrra
7•Is.thiY a repair to an_etisting well: bDYes or iiONq.• - .err of Mir►rennf hire 1Kcn pmyide4 to JO oil*ll(owner, •
If Oils Iso(eporK fit Nit Ylnhwl liTacamm-r1,10i07n`lrffonnarkrl oerd t c ibaln the rnnrlrre of the
repcii'amlcrd21 lenrurksie tiaa e,rar the bark of this form. - 23.Site diagram or additional well details: '-
You-May use the hack of this page to provide additional well site details or Well -
8..Numberof welh constructed: 1 construction details: You.rnae also attach additional pages if necessar}•.
For'mrrltlple.lifcetlun or oni-iacer supply m.Ttls.ONLY with nce someconitrurllwr,yob eon
sabnaronc.jarm. _ . . -S!JftMIITTALINSTfICTiONS
9.Total welt detitli below land surface: 35 Oh) 24a. Far All Wells:• Sithtnit this form within 30 days of completion of well
For rrenliipie itcts'lijr nNrfepths lfdlfji were(e ample-3@200'and'd@ 1001' - - conslntction to the following:.
1
10.Static Water level below top of casings?? 0 9 (ft.) ' ,Diviriun'of Water Resources,Information i'racessing Unit,.
If wmer leyi,l1s,nlitme eas(tix.use'•+'• 1617 Mail Service Centcr,.Ralcigh,NC 27699-1617
8.25° I-
IL Burcltgtc diameter (in) gals•For Iitim(InR�4 [Ir ONLY: in addition to sending theform to the adds in
24a aboio,also submit a•copy of this fomi within 30 days-of completion of well
it well constntetioii method:NSA & Direct Push constnictimin to the following:
ti.c.augcr..rotary.cables direct push.etc.)
Division of Water Resources,ifnderground Injection Control Program,
• . FOR WATER SUPPLY WELLS' 1636 Mal Service`pettier,Raleigh,NC 27699-1636 '
13a,Yield Wm) .Method of test: 24e.For.Water Sun!v.tC Injection Wells: .
• Also submit one copy of this fifth within 30 daysof completion of- ,
13h.Disinfection tylie:• • - Amount: well construction to the county health department of the county.where
constricted.
Fonti GW-i North Carolina Departmentf Environono and Namrsl Resources-Division of Rater
,o Rewtrem Revised August 20 I3
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