GW1--01046_Well Construction - GW1_20240212

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor� � Information: 1
TerryWhite
h Ire 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I 1
3287-A
ft. ft. I
NC Well Contractor Certification Number
ET 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS J]i MATERIAL
ft. ft. I in.
Company Name _16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 tt. 10 ft' 1 in' Sch40 PVC
3.Well Use(check well use): ft. ft , in
Water Supply Well: 17.SCREEN - ;
FROM TO DIAMETER I 'SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 10 ft' 20 fL 1 in.1 !'0.010 Sch40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R, ft. is
IndustriallCommercial OResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 - ft' 8 - ft. Bentonite Poured/10LB
x Monitoring oRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19;SAND/GRAVELPACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 8 ft. 20 ft- j
Experimental Technology EDSubsidence Control ft. ft. I.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) -., '
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
' fL See Consultant Log
4.Date Well(s)Completed:2/6/24 Well m#1- 2 rt. ft.ft Well Location: ft ft
Vacant Building ft. it. ' ....4.rPtLi
. .�r1!`r
1
Facility/Owner Name Facility IDS(if applicable) ft. ft. j
t
514 S. Elm St. Greensboro 27406 ft. ft. , i-tj 12 2014
Physical Address,City,and Zip ft. Ai p yr;J1 ',ttr nsf" °
REMARKS 21.REARKS 'tf9',`£r''4S
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 04 00 N 79 47 28 W
/ _aiii 2/7/2024
6.Is(are)the well(s)IJ 'Permanent orTemporary Signature of red Well Contractor Date
--- _ - _ _ _ _- — _ - By signing this form,I hereby certtty that the well(s)was(were)constructed in accordance --—
7.Is this a repair to an existing well: JYes or ONo with 15,4 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
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drilled:one SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
if For multiple wells list all depths different(example-3@200'and 2@100) construction to the following:
1
10.Static water level below top of casing:9.26 (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:2 1/4 (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Direct Push above,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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i ,
13a.Yield(gpm) Method of test: 24c.For Water Suanly&Injection 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 td the 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