GW1--00940_Well Construction - GW1_20240209

6[ "Print Form .]
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Terry White :'14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3287-A It- ft. I
NC Well Contractor Certification Number 15:OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
IET FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name
VVM�4014 97 .:16.INNER CASING OR TUBING(geothermal closed-loop) .: "
2.Well Construction Permit#: nl� 'T 'Ta! FROM ' TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 R• 9 ft: 2 ' in- Sch40 PVC
ft. ft. I in.
3.Well Use(check well use):
Water Supply Well:
Water 17.SCREEN :.
Agricultural 0Municipal/Public
FROM TO DIAMETERI SLOT SIZE THICKNESS MATERIAL
g ft 24 fa 2 1D' 0.010 Sch40 PVC
DGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irrigation - -__�.~~- -- -- -- ---- .-FROM - TO MATERIAL EMPLACEMENT METHOD&AMOUNT -..
I Non-Water Supply Well: 3 ft. 7 it Bentonite Poured/100LB
Monitoring DRecovery 0 ft• 3 It Cement Poured/45LB
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)
QAquifer Storage and Recovery 0ISalinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD-
EDAquifer Test IoStormwater Drainage 7 ft. 24.2 ft. #2 Sand Poured
0BExperimental Technology Subsidence Control ft. ft. I
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sbeets if necessary)
Geothermal(Heating/Cooling g Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,wain sae,etc.)
ft.
ft. See Consultant Log
4.Date Well(s)Completed:1/22/2024 Well ID#M W 13 ft ft
Sa.Well Location: ft. ft. ' p ti�'''--4 rq?�F�,,,
Monticello Oil ft. ft. t
Facility/Owner Name Facility 1D#(if applicable) ft. ft. 1 rt(f 0 9 9074
DOT ROW(Intersection Of Ben*Rd./Old Reidsville Rd.) Browns Summit,27214 ft. ft. L
hikaPel if.n,a,-,. ,
tio
Physical Address,City,and Zip ft. ft. I DWcy• �'M Z'g
Guildford 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.222624 N 79.676227 w 272440.
` Gf�i 1/26/2024
6.Is(are)the well(s)JX Permanent -or OTempora_ry Signature of ified Well Contractor Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or E3No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:one SUBMITTAL INSTRUCTIONS
2
9.Total well depth below land surface: 24. (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00') construction to the following: i
10.Static water level below top of casing: 15.79 (ft.) Division of Water Resources;Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Augerabove,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1
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 Supply&IniectioniWells: 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 tile county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016